Green Cross Home Care Services, Inc.

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the provider failed to ensure the Condition of Participation for Clinical Records requirement was met by failing to: Consult the physician to clarify contradictory orders on the plan of care (refer to G572); Ensure the plan to care includes directions for care and necessary equipment (refer to G574); Ensure medications were given only in accordance with physician orders (refer to G580); Ensure the plan to care was reviewed and revised at least every 60 days (refer to G588); and Notify the physician when orders could not be followed and the plan of care needed to be altered (refer to G590). The cumulative effect of these systemic issues resulted in the HHA’s inability to assure that patient’s needs would be met.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the provider failed to ensure the Condition of Participation for Clinical Records requirement was met by failing to: Ensure the accuracy of the clinical record by documenting care during times it could not have been provided (refer to G1012); Ensure documentation of interventions, including medications and tube feedings administered (refer to G1014); and Document and maintain accurate contact information (refer to G1018). The cumulative effect of these systemic issues resulted in the HHA’s inability to assure that patient’s needs would be met.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on review of the provider’s Policies and Procedures, patient record review and interview, the provider failed to implement its policies and procedures and to document viable individualized emergency plans for 2 of 5 sampled patients (Patients #1 and #5). Findings Include: The provider’s Policy and Procedure titled Medical Record Content, revised February 2024, documents the Policy, “The Agency will provide an accurate and current medical record for every patient seen by the Agency” and under Procedure, “Each medical record will contain the following: … Individualized patient emergency preparedness plans.” 1) Review of the record reveals Patient #1 is a 3-year-old child and re-started care on 01/01/25 due to a payor change. Patient #1’s Home Health Certification and Plan of Care for 02/01/25 to 04/01/25 documents under Emergency Preparedness, “Emergency Triage: 2. Not life threatening but would suffer severe adverse effects from interruption of services.” Patient #1’s Patient Individualized Emergency Plan, dated 03/16/24 and signed by the Director of Nursing, documents their emergency priority level as “D2 – Category 2 - moderate level of skilled care; caregiver can provide basic care”; indicates by checkboxes below “To facilitate appropriate care, transportation and/or evacuation the patient plans to:” the responses “remain in the home” and “nonemergency inpatient admission”; and indicates special needs as “bedbound,” “apnea monitor,” “apnea monitor is portable with back-up battery,” and “tube feeding” but no mention of a suction machine or feeding pump, although both are used in her daily care. Further review of Patient #1’s record reveals no more recent Patient Individualized Emergency Plan. During a home visit to Patient #1 on 04/30/25 at 4:30 PM, the parent of Patient #1 stated in case of emergency such as a hurricane they would take Patient #1 to [name of hospital] to plug in the tube feeding pump in a hallway and believed they could do this because they went to the same hospital during another hurricane when the patient was sick and the patient was admitted and received good care. During this home visit on 04/30/25 at 4:30 PM, the Director of Nursing confirmed this plan and confirmed to the parent they can take the patient and plug in their tube feeding equipment in the hospital lobby to ride out the hurricane because only “Level 1” patients on “trachs (tubes in their throats to breath) or vents (machines to help them breath)” can go to special needs shelters. The Director of Nursing insisted the hospital allows people to stay in the lobby and plug in their medical equipment for the duration of hurricanes even if they do not need admission. 2) Review of the record reveals Patient #5 started care on 10/24/24 and is 17 years old. Patient #5’s Home Health Certification and Plan of Care for 4/22/25 to 06/20/25 documents they receive intravenous Wilate (a plasma product to treat bleeding episodes) twice a week and documents under Emergency Preparedness, “Emergency Triage: 2. Not life threatening but would suffer severe adverse effects from interruption of services,” and does not document an emergency contact or responsible party although Patient #5 is a minor child. Patient #5’s Patient Individualized Emergency Plan, dated 10/24/24 with signature for a Registered Nurse, documents their emergency priority level as “D2 – Category 2 - moderate level of skilled care; caregiver can provide basic care”; also contains no contact information for an emergency contact or responsible party; does not indicate any plans in case of emergency or evacuation; indicates their special needs as “Intravenous medications: Wilate (1030U [1030 units]) IV [intravenous] infuse”; and contains no plan for how that medication would continue to be administered in case of emergency or if the doctor determined the patient could do without it for a period of time. Further review of Patient #5’s record reveals no more recent Patient Individualized Emergency Plan since 10/24/24. During interview on 05/07/25 at 2:52 PM, the Director of Nursing denied needing individualized emergency plans for any of their patients because she stated the emergency status for all of their patients is “Level 3” since they don’t have any patients with “trachs or vents”; that they can all go without care for 48-72 hours; and she denied all patients needing an emergency plan.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview, the provider failed to obtain the signature of 1 of 5 sample patients (Patient #5) or, in the case of a minor child, their legal representative for notice of their rights and responsibilities. Findings Include: Review of the record reveals Patient #5 started care on 10/24/24 and is 17 years old, but no documentation that the notice of rights and responsibilities was provided to the patient’s legal representative, since Patient #5 is a minor. During interview on 05/07/25 at 2:36 PM, when the Director of Nursing was asked how patients or their representatives are informed of their rights, she said staff call and make sure they are home and ask them if it is ok to come out and let them know they can choose the company. Upon rephrasing the question to ask how they get notice of what their patient rights are, she said we call and tell them, and ask if it is ok to come out.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on interview and record review the provider failed to inform patients and/or their representatives of charges and expected payment sources in advance of care for 1 of 5 patients (Patients #5). Findings Include: Review of the record reveals Patient #5 started care on 10/24/24 and is 17 years old. Further review of the record reveals Patient #5’s first name only as a signature on their Patient Individualized Emergency Plan and for a Receipt of Description of Medicaid Fraud and no notice of their payment source or expected charges for services, if any. Further record review revealed no evidence that a responsible party received information about charges for services and their responsibility for payment, if any, since Patient #5 is a minor child. During interview on 05/07/25 at 2:36 PM, when the Director of Nursing was asked how patients or their representatives are informed of any charges and the payor for their home health care, she replied, “Everyone knows when they go to hospital they have insurance,” but also said a patient with a wound or “IV” [intravenous access] might have Share-Of-Cost Medicaid; when again asked how the patient is informed who will pay for services, she said, “They know before us” and “Patients never ask for cost.” The Director of Nursing described no method for informing patients or their representatives of any charges in advance or of the expected payor source for their treatment.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of the provider’s Policies and Procedures, clinical record review and staff interview, the provider failed to notify the physician when orders could not be followed and the plan of care needed to be altered for 1 of 5 sampled patients (Patient #1). Findings Include: Review of the record reveals Patient #1 is a 2-year-old child with diagnoses that include a growth disorder and failure to thrive. Patient #1’s Home Health Certification and Plan of Care for the certification period of 02/01/25 to 04/01/25, with physician signature dated 02/07/25, documents Medications that include “NORDITROPIN 1 MG [milligram] ONCE DAYLI subcutaneous (SQ) C” and, 2 lines below that, “Somatropin 1 MG Subcutaneous Prefilled syringe 1mg daily SQ C night.” Somatropin is the generic name for Norditropin, a growth hormone therapy. Further review of the record reveals no evidence the order for daily subcutaneous growth hormone injections was changed or clarified to avoid duplicate administration. Patient #1’s nurse’s note by Staff A for 03/28/25 documents, “Growth hormone shot not administered because there’s no more needles, parent is aware and pt [patient] must see the doctor first.” Patient #1’s nurses’ notes for 03/29/25 and 03/30/25 do not document whether the growth hormone injection was administered. Patient #1’s nurses’ notes by Staff A for 04/01/25, 04/02/25, and 04/03/25 also document, “Growth hormone shot not administered because there’s no more needles, parent is aware and pt must see the doctor first.” Further review of the nurses’ notes reveals no evidence the physician was made aware the growth hormone shots were not given. During interview with Registered Nurse, Staff D on 04/30/25 at 4:30 PM during the home visit to Patient #1, Staff D denied a separate medication record and reported nurses document medication administration in the nurses’ notes. During interview on 05/05/25 at 2:25 PM, the Director of Nursing said, “We don’t need to call the doctor if they’re out of shots,” that they would only need to notify the doctor if the nurse had them and chose not to follow the plan of care for some reason. During telephonic interview on 05/05/25 at 2:44 PM Licensed Practical Nurse, Staff A reported Patient #1 was out of growth hormone shots for about 2 months and needed to see the pediatrician again to get a new order; that she put it in her notes; but denied notifying the Registered Nurse or physician.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record review and interview, the Administrator failed to be responsible for all day-to-day operations to ensure corrective actions were developed and carried out to correct deficient practices. Findings include: Review of the provider’s documentation revealed proposed actions to correct previously identified deficiencies related to QAPI (Quality Assurance and Performance Improvement) were not implemented since there was no documentation of QAPI activities to collect data, assess quality of care, or make improvements in care delivery since 2023 (refer to G640, G642, G644, G646, G654, G658, and G660). During interview on 05/07/25 at 10:06 AM, the Administrator stated he did participate in development of plans to correct identified deficiencies but denied taking any actions to ensure Quality Assessment or Performance Improvement activities in 2025 and wasn’t sure if such activities had taken place in 2024. During further interview on 05/07/25 at 12:34 PM the Administrator expressed difficulty to direct family members.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure 1 of 15 staff (Staff A) who provide services directly to patients had an eligible level 2 background screen as required by the state; and failed to ensure 5 of 8 sampled staff (Staff A, C, E, F, and G) were entered in the clearinghouse roster (Background Screening Clearinghouse Roster) as required by the state. Findings include: 1) Review of the personnel record reveals Staff A was hired on 06/27/24 as an LPN (Licensed Practical Nurse) and her Clearinghouse Background Screening Result printed by the Administrator on 03/19/25 at 12:49 PM showed she was “Not Eligible” with an “eligibility determination date” of 12/10/24. Review of Staff A’s Clearinghouse Background Screening on AHCA’s website on 05/02/25 revealed she was still “Not Eligible.” A printed and signed statement from the DON (Director of Nursing) documents Staff A provided services exclusively to one patient since 12/10/24. Review of Staff A’s Payroll Detail revealed she made 93 visits to Patient #1 since 12/10/24, during which she stayed between 4 and 15 hours each visit. Review of the record reveals Patient #1 was a 3 year-old child with skilled nursing needs. During telephone interview on 05/02/25 at 5:32 PM the DON said she was assigning Staff A to another child; when the surveyor informed the DON of Staff A’s “Not Eligible” background screening results and that Staff A cannot be going into patients’ homes or providing direct care, the DON said this would leave the new child without care and Staff A out of work, but then she agreed to notify Staff A that she cannot work. Review of the clearinghouse roster revealed Staff A was not on the provider’s roster as of 05/07/25 2) Review of the personnel record reveals Staff C was hired on 02/24/21 and as of 04/29/25 was the Alternate Administrator. Review of the clearinghouse roster revealed Staff C was not on the roster as of 05/07/25. 3) Review of the personnel record reveals Staff E was hired on 05/24/24 and is a Home Health Aide. Review of the clearinghouse roster revealed Staff E was not on the roster as of 05/07/25. 4) Review of the personnel record reveals Staff F was hired on 05/14/24 and is a Physical Therapist Assistant. Review of the clearinghouse roster revealed Staff F was not on the roster as of 05/07/25. 5) Review of the personnel record reveals Staff G was hired on 11/14/24 and is a Physical Therapist. Review of the clearinghouse roster revealed Staff G was not on the roster as of 05/07/25.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview, the Director of Nursing failed to assure plans of care were complete and implemented with updates every 60 days for 2 of 5 patients (Patients #1 and 5). Findings include: 1) Review of Patient #1’s record reveals she is a 2-year-old child who is fed through a tube in the stomach. Patient #1’s Home Health Certification and Plan of Care for the certification period of 02/01/25 to 04/01/25 documents, “SN indicated instruction, preparation, and administration of tube feedings via bolus every four hours during the day and continuously at night. Flush the tube with 30 ml [milliliters] of water before and after feeding the substance. check tube placement, check residual before feeding hold feedings for over 100 cc. perform site care daily or as needed.” Patient #1’s Home Health Certification and Plan of Care does not include directions for what formula or formulation of tube feeding to administer, how much to give with each bolus during the day, how much to give and at what rate it should be given at night, whether it should be administered by a tube feeding pump, or whether the nurse administers medications. Patient #1’s Home Health Certification and Plan of Care for the certification period of 02/01/25 to 04/01/25 also documents her DME (Durable Medical Equipment) as nebulizer, wheelchair, and special chair but does not include a tube feeding pump. During a home visit on 04/30/25 at 4:30 PM, the provider’s Registered Nurse Staff D was observed providing care for Patient #1 and Staff D reported she mixes Patient #1’s tube feedings (4 ingredients in water) according to directions from a recent Emergency Department discharge since there are no directions for this on a plan of care. Patient #1 was observed connected to a tube feeding pump with tube feeding running at 90 ml/hr [milliliters per hour] during the visit. During interview on 05/05/25 at 3:30PM, the Director of Nursing stated she does not put the tube feeding on Patient #1’s plan of care because on weekdays another provider gives the tube feeding boluses and their nurse only gives the 4 PM bolus; when asked about the weekends and holidays, she did not answer the question but said “You act like I don’t know what I am doing.” Further review of Patient #1’s record reveals a Home Health Certification and Plan of Care for the certification period of 07/14/24 to 09/11/24, a Home Health Certification and Plan of Care for the certification period of 09/12/24 to 11/10/24, a Home Health Certification and Plan of Care for the certification period of 11/11/24 to 01/09/25, then a lapse with the next Home Health Certification and Plan of Care for the certification period of 02/01/25 to 04/01/25, and no Home Health Certification and Plan of Care after 04/01/25. Further review of the record reveals no evidence of review and/or revision to the plan of care within 60 days of 11/11/24 and that the next plan of care was not created and effective until 02/01/25 although the patient was not discharged and her care continued. There was also no evidence of review and/or revision to the plan of care within 60 days of 02/01/25 or after the last plan of care end date of 04/01/25. During interview on 05/05/25 at 3:08 PM, the Director of Nursing stated the Plan of Care is good for 6 months because insurance companies provide authorizations for 6 months. During further interview on 05/05/25 at 3:47 PM she was specifically asked about Patient #1’s Plan of Care after the previous certification period ended on 04/01/25 and she stated, “We don’t need it, we do the plan of care for 6 months because insurance gives auth [authorization] for 6 months at a time.” The Director of Nursing did not acknowledge the physician orders on a plan of care are for 60 days at a time and the plan of care must be updated and renewed before it expires if the patient continues to receive care. 2) Patient #5’s Home Health Certification and Plan of Care documents they started care on 10/24/24 for treatment of a bleeding disorder, at which time they were 16 years old. Patient #5 was 17 years old at the time of the survey. Review of Patient #5’s “Patient Profile,” Patient Individualized Emergency Plan,” and “Home Health Certification and Plan of Care” reveals no documentation of a name and contact information for Patient #5’s parent, caregiver or legal representative or of an Emergency Contact. Patient #5’s referral for home health documents services requested as “IV Therapy (twice weekly Wilate [plasma product to treat bleeding disorder] infusion.” Patient #5’s Home Health Certification and Plan of Care (HHCPOC) for 10/24/24 to 12/22/24 documents, “SN [skilled nurse] twice weekly x [for] 9 weeks, effective date 10/25/24” and medications that include “Wilate 1000-1000 unit Intravenous Kit 1 doses twice a week x9 weeks intravenous (IV) C Infuse 6000 VWF units (5400-6600) slow IV” but also documents with nursing instructions, “Using aseptic technique, SN to infuse/administer, instruct patient/caregiver to infuse/administer Wilate (1030u) infuse 6000 VWF units (5400-6600) slow IV Monday, Wednesday and Friday.” No evidence was found in the record of attempt to clarify whether the medication should be given twice weekly or on Mondays, Wednesday, and Fridays. Furthermore, the physician did not cosign the HHCPOC until 01/02/25, too late to make any timely corrections. Patient #5’s subsequent three HHCPOCs for 12/23/24 to 02/20/25, 02/21/25 to 04/21/25, and 4/22/25 to 06/20/25 continued to document the nurse should visit twice weekly and in medications that Wilate should be given twice weekly, but in nursing directions that Wilate should be given on Mondays, Wednesday, and Fridays. Patient #5 received Wilate infusions at varying intervals, from once to 3 times weekly as described below Review of nursing notes revealed Patient #5 received visits with Wilate infusions twice weekly, on Tuesdays and Thursdays, from 01/02/25 to 02/15/25; then three times weekly, on Tuesdays, Thursdays and Fridays from 02/16/25 to 02/22/25; twice the week of 02/23/25 to 03/01/25; then a 6-day lapse with 1 infusion the week of 03/02/25 to 03/08/25, before resuming twice weekly infusions on 03/10/25 until at least 04/11/25. During telephone interview on 05/06/25 at 4:15 PM with Patient #5’s primary physician’s staff, that staff member reported checking with the primary physician who denied prescribing Wilate and did not know if Patient #5 should still be on it. Further review of Patient #5’s HHCPOC revealed no contact information for another physician.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the provider failed to ensure documentation of interventions, including the medications and tube feedings administered to 1 of 5 sampled patients (Patient #1). Findings include: Review of Patient #1’s record reveals she is a 2-year-old child who is fed through a tube in the stomach. Patient #1’s Home Health Certification and Plan of Care for the certification period of 02/01/25 to 04/01/25 documents, “SN [Skilled Nurse] indicated instruction, preparation, and administration of tube feedings via bolus every four hours during the day and continuously at night” and does not specify whether the skilled nurse administers medications. Patient #1’s “RN Hourly” note dated 03/29/25 for 3:16 PM to 7:00 AM documents at 6:00 AM, “meds [medications] given as ordered” but does not specify the names, dosages, or routes of administration. Patient #1’s “LVN [Licensed Vocational Nurse] Hourly” note dated 03/30/25 for 7:10 PM to 7:00 AM documents at 6:00 AM, “meds given as ordered.” Patient #1’s “RN [Registered Nurse] Hourly” note dated 04/04/25 for 4:10 PM to 12:00 AM documents at 10:00 PM, “meds as ordered.” Patient #1’s “LVN Hourly” note for 04/05/25 from 8:02 AM to 4:02 PM documents, “1000 Medications administered as ordered. 1200 Feeding provided as scheduled,” “0200 Medications administered via gtube [gastric tube, a tube in the stomach]” and “0402 Feeding given as ordered” without specifying the names, dosages, or routes of medications or the formula and route of feeding, since Patient #1 has a gastric tube. Patient #1’s “RN Hourly” note for 04/05/25 from 4:10 PM to 12:00 AM documents at 10:00 PM, “meds given as ordered.” Patient #1’s “RN Hourly” note for 04/06/25 from 3:02 PM to 11:00 PM documents at 10:00 PM, “meds given as ordered 5ml [5 milliliters] water before and after meds.” Patient #1’s “RN Hourly” note dated 04/11/25 for 4:09 PM to 7:00 AM documents at 10:00 PM, “meds given as ordered” and at 06:00 AM, “meds given as ordered.” Patient #1’s “RN Hourly” note dated 04/13/25 for 4:06 PM to 7:00 AM documents at 10:00 PM “meds given a ordered” and at 05:45 AM “meds given as ordered.” Patient #1’s “RN Hourly” note dated 04/19/25 for 12:28 PM to 12:00 AM documents at 2:00 PM “meds given as ordered” and at 10:00 PM “meds given ad ordered” (sic). Patient #1’s “RN Hourly” note dated 04/20/25 for 3:01 PM to 11:00 PM documents at 10:00 PM, “meds given as ordered.” Patient #1’s “LVN Hourly” note dated 04/21/25 documents at 5:30 PM, “Feeding provided, formula via gtube at 110 ml/hr [milliliters per hour] tolerated well” and does not indicate the formula provided. During a home visit to Patient #1 with interview on 04/30/25 at 4:30 PM, Registered Nurse, Staff D reported they document giving medications and tube feedings on the nursing note and do not also document in a medication administration record or another place.”

“Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); This Element is not met as evidenced by: Based on record review and interview, the provider failed to document and maintain relevant accurate contact information for 2 of 5 sampled patients (Patients# 3 and 5). Findings include: 1) Patient #3’s Home Health Certification and Plan of Care for the certification period 04/03/25 to 06/01/25 documents they started care on 04/03/25 for Home Health Aide services 13 hours daily Monday through Thursday and 24 hours a day Friday through Sunday, effective date “04/03/2001.” A home visit to Patient #3 was attempted at the address of record on 05/02/25. However, during a telephone interview with Patient #3’s Home Health Aide, Staff L who is a family member and reports she lives and works with him daily, on 05/02/25 at 12:25 PM, Staff L reported she and Patient #3 had moved to another county the previous Monday and had not informed the Home Health Agency of the new address. 2) Patient #5’s Home Health Certification and Plan of Care documents they started care on 10/24/24, at which time they were 16 years old. Patient #5 was 17 years old at the time of the survey. Review of Patient #5’s “Patient Profile,” Patient Individualized Emergency Plan,” and “Home Health Certification and Plan of Care” reveals no documentation of a name and contact information for Patient #5’s parent, caregiver or legal representative or of an Emergency Contact.”

“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, Home Health Agency policy 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 implementation of a Quality Assessment Program to monitor effectiveness, safety of services, and quality of care as well as develop, implement, evaluate, and maintain an effective, ongoing, Home Health Agency (HHA)-wide, data-driven program. The findings include: Cross Reference G0644: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to a QAPI program was in place that utilized relevant data in the design of its program. Cross Reference G0658: Based on attempted record review, agency policy review, and staff interviews, the agency failed to conduct and document performance improvement projects to improve the quality of services provided with the potential to affect all patients. Cross Reference G0646: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to provide proof of performance improvement activities for review. Cross Reference G0654: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to track adverse patient events, analyze their causes, and implement preventive actions. Cross Reference G0642: Based on attempted record review, agency policy review, and interview the home health agency failed to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. Cross Reference G0660: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency Governing Body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained. .”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on staff interview and attempted record review, the Home Health Agency failed to provide proof of having conducted exercises to test the emergency plan at least annually. The findings include: On 3/18/25 at 10:00am, during an entrance conference with the Director of Nursing/Owner (DON), proof of Emergency Plan activation for review of meeting the testing requirements was requested. This item was again requested on 3/18/25 at 12:50pm 3:15pm, and 4:00pm. The Administrator stated he was working on the items requested and would have them on 3/19/25 when the surveyors returned in the morning. On 3/19/25 the Administrator arrived at the Home Health Agency at 10:00am. When asked for the requested items, he stated he was still working on some of the items. The proof of Emergency Plan activation for review of meeting the testing requirements. was not provided.”

“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 record review and Home Health Agency policy review, it was determined that the Home Health Agency failed to electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment to the Centers for Medicare and Medicaid Services (CMS) system, within 30 days of completing the assessment of the patient for 5 out of 6 patients reviewed. The findings include: A review of the Home Health Agency’s year to date (1/1/25- 3/13/25) error rate for failure to transmit a completed OASIS assessment within 30 days of completing the assessments revealed an error rate of 52.97%, reflecting 9 OASIS assessments out of 17 completed not sent in within 30 days of completion: Patient #1: OASIS assessment completed 12/8/24; transmitted 1/25/25; Patient #2: OASIS assessment completed 1/20/25; transmitted 2/20/25; Patient #4: OASIS assessment completed 12/12/24; transmitted 1/25/25; Patient #5: OASIS assessment completed 11/13/24; transmitted 1/12/25; Patient #6: OASIS assessment completed 11/28/24; transmitted 1/25/25. A review of the Home Health Agency’s policy titled “Reporting of OASIS Information” (revised 2/2024) revealed: Policy: The Agency will report required data collection for OASIS. Purpose: To define encode and transmittal of OASIS data. Procedure: The Agency will report electronically all OASIS data collected according to current federal and/or state requirements.”

“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 staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. The findings include: On 3/18/25 at 10:00am, during an entrance conference with the Director of Nursing/Owner (DON), proof of their Quality assessment and performance improvement (QAPI) program was requested for review. This item was again requested on 3/18/25 at 12:50pm 3:15pm, and 4:00pm. The Administrator stated he was working on the items requested and would have them on 3/19/25 when the surveyors returned in the morning. On 3/19/25 the Administrator arrived at the Home Health Agency at 10:00am. When asked for the requested items, he stated he was still working on some of the items. On 3/19/25 at 10:50am, the Director of Nursing was asked if she had proof of the agency’s QAPI program to provide, such as agendas and sign in sheets, and any performance improvement projects to review. She stated we don’t have sign in sheets, we do that over the phone. Proof of the Home Health Agency’s QAPI program was not provided, which resulted in the inability to determine if the Home Health Agency showed measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. A review of the Home Health Agency’s policy titled “Quality Assurance and Performance Improvement Plan and Program” (revised 2/2024) revealed: Policy: The Agency will establish an ongoing Agency wide, data driven program of quality assurance and performance improvement and maintain documentary evidence of its program. Purpose: To continually collect and analyze data to improve the Agency’s performance of clinical and other processes, specifically as follows: Continuously improve processes of patient care/services as well as outcomes of care. Communicate information internally and externally. Use a systematic approach to problem identification and resolutions. Conform to all applicable federal/state rules/regulations as well as accreditation home care standards.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to a QAPI program was in place that utilized relevant data in the design of its program. The findings include: On 3/18/25 at 10:00am, during an entrance conference with the Director of Nursing/Owner (DON), proof of their Quality assessment and performance improvement (QAPI) program was requested for review. This item was again requested on 3/18/25 at 12:50pm 3:15pm, and 4:00pm. The Administrator stated he was working on the items requested and would have them on 3/19/25 when the surveyors returned in the morning. On 3/19/25 the Administrator arrived at the Home Health Agency at 10:00am. When asked for the requested items, he stated he was still working on some of the items. On 3/19/25 at 10:50am, the Director of Nursing was asked if she had proof of the agency’s QAPI program to provide, such as agendas and sign in sheets, and any performance improvement projects to review. She stated we don’t have sign in sheets, we do that over the phone. Proof of the Home Health Agency’s QAPI program was not provided. A review of the Home Health Agency’s policy titled “Quality Assurance and Performance Improvement Plan and Program” (revised 2/2024) revealed: Policy: The Agency will establish an ongoing Agency wide, data driven program of quality assurance and performance improvement and maintain documentary evidence of its program. Purpose: To continually collect and analyze data to improve the Agency’s performance of clinical and other processes, specifically as follows: Continuously improve processes of patient care/services as well as outcomes of care. Communicate information internally and externally. Use a systematic approach to problem identification and resolutions. Conform to all applicable federal/state rules/regulations as well as accreditation home care standards.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to provide proof of performance improvement activities for review. The findings include: On 3/18/25 at 10:00am, during an entrance conference with the Director of Nursing/Owner (DON), proof of their Quality assessment and performance improvement (QAPI) program was requested for review. This item was again requested on 3/18/25 at 12:50pm 3:15pm, and 4:00pm. The Administrator stated he was working on the items requested and would have them on 3/19/25 when the surveyors returned in the morning. On 3/19/25 the Administrator arrived at the Home Health Agency at 10:00am. When asked for the requested items, he stated he was still working on some of the items. On 3/19/25 at 10:50am, the Director of Nursing was asked if she had proof of the agency’s QAPI program to provide, such as agendas and sign in sheets, and any performance improvement projects to review. She stated we don’t have sign in sheets, we do that over the phone. Proof of the Home Health Agency’s QAPI program was not provided. A review of the Home Health Agency’s policy titled “Quality Assurance and Performance Improvement Plan and Program” (revised 2/2024) revealed: Policy: The Agency will establish an ongoing Agency wide, data driven program of quality assurance and performance improvement and maintain documentary evidence of its program. Purpose: To continually collect and analyze data to improve the Agency’s performance of clinical and other processes, specifically as follows: Continuously improve processes of patient care/services as well as outcomes of care. Communicate information internally and externally. Use a systematic approach to problem identification and resolutions. Conform to all applicable federal/state rules/regulations as well as accreditation home care standards. A review of the Home Health Agency’s policy titled “Performance Improvement Projects: (revised 2/2024) revealed: Policy: The Agency will conduct performance improvement projects. Purpose: To meet Medcare Conditions of Participation for conducting performance improvement projects. Procedure: 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. 3. The Agency should have one performance improvement project either in development, ongoing, or completed each year. 4. The Agency decides, based on the QAPI program activities and data, what projects are indicated and the priority of the projects.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to track adverse patient events, analyze their causes, and implement preventive actions. The findings include: On 3/18/25 at 10:00am, during an entrance conference with the Director of Nursing/Owner (DON), proof of their Quality assessment and performance improvement (QAPI) program was requested for review. This item was again requested on 3/18/25 at 12:50pm 3:15pm, and 4:00pm. The Administrator stated he was working on the items requested and would have them on 3/19/25 when the surveyors returned in the morning. On 3/19/25 the Administrator arrived at the Home Health Agency at 10:00am. When asked for the requested items, he stated he was still working on some of the items. On 3/19/25 at 10:50am, the Director of Nursing was asked if she had proof of the agency’s QAPI program to provide, such as agendas and sign in sheets, and any performance improvement projects to review. She stated we don’t have sign in sheets, we do that over the phone. Proof of the Home Health Agency’s QAPI program was not provided. A review of the Home Health Agency’s policy titled “Quality Assurance and Performance Improvement Plan and Program” (revised 2/2024) revealed: Policy: The Agency will establish an ongoing Agency wide, data driven program of quality assurance and performance improvement and maintain documentary evidence of its program. Purpose: To continually collect and analyze data to improve the Agency’s performance of clinical and other processes, specifically as follows: Continuously improve processes of patient care/services as well as outcomes of care. Communicate information internally and externally. Use a systematic approach to problem identification and resolutions. Conform to all applicable federal/state rules/regulations as well as accreditation home care standards. A review of the Home Health Agency’s policy titled “Performance Improvement Projects: (revised 2/2024) revealed: Policy: The Agency will conduct performance improvement projects. Purpose: To meet Medcare Conditions of Participation for conducting performance improvement projects. Procedure: 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. 3. The Agency should have one performance improvement project either in development, ongoing, or completed each year. 4. The Agency decides, based on the QAPI program activities and data, what projects are indicated and the priority of the projects.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on staff interview, policy review, and attempted record review, it was determined that the Home Health Agency failed to conduct performance improvement projects. The findings include: On 3/18/25 at 10:00am, during an entrance conference with the Director of Nursing/Owner (DON), proof of their Quality assessment and performance improvement (QAPI) program and performance improvement projects were requested for review. This item was again requested on 3/18/25 at 12:50pm 3:15pm, and 4:00pm. The Administrator stated he was working on the items requested and would have them on 3/19/25 when the surveyors returned in the morning. On 3/19/25 the Administrator arrived at the Home Health Agency at 10:00am. When asked for the requested items, he stated he was still working on some of the items. On 3/19/25 at 10:50am, the Director of Nursing was asked if she had proof of the agency’s QAPI program to provide, such as agendas and sign in sheets, and any performance improvement projects to review. She stated we don’t have sign in sheets, we do that over the phone. Proof of the Home Health Agency’s performance improvement projects was not provided. A review of the Home Health Agency’s policy titled “Quality Assurance and Performance Improvement Plan and Program” (revised 2/2024) revealed: Policy: The Agency will establish an ongoing Agency wide, data driven program of quality assurance and performance improvement and maintain documentary evidence of its program. Purpose: To continually collect and analyze data to improve the Agency’s performance of clinical and other processes, specifically as follows: Continuously improve processes of patient care/services as well as outcomes of care. Communicate information internally and externally. Use a systematic approach to problem identification and resolutions. Conform to all applicable federal/state rules/regulations as well as accreditation home care standards. A review of the Home Health Agency’s policy titled “Performance Improvement Projects: (revised 2/2024) revealed: Policy: The Agency will conduct performance improvement projects. Purpose: To meet Medcare Conditions of Participation for conducting performance improvement projects. Procedure: 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. 3. The Agency should have one performance improvement project either in development, ongoing, or completed each year. 4. The Agency decides, based on the QAPI program activities and data, what projects are indicated and the priority of the projects.”

“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 staff interview, policy review, and attempted record review, it was determined that the Home Health Agency Governing Body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained. The findings include: On 3/18/25 at 10:00am, during an entrance conference with the Director of Nursing/Owner (DON), proof of their Quality assessment and performance improvement (QAPI) program was requested for review. This item was again requested on 3/18/25 at 12:50pm 3:15pm, and 4:00pm. The Administrator stated he was working on the items requested and would have them on 3/19/25 when the surveyors returned in the morning. On 3/19/25 the Administrator arrived at the Home Health Agency at 10:00am. When asked for the requested items, he stated he was still working on some of the items. On 3/19/25 at 10:50am, the Director of Nursing was asked if she had proof of the agency’s QAPI program to provide, such as agendas and sign in sheets, and any performance improvement projects to review. She stated we don’t have sign in sheets, we do that over the phone. Proof of the Home Health Agency’s QAPI program was not provided. A review of the Home Health Agency’s policy titled “Quality Assurance and Performance Improvement Plan and Program” (revised 2/2024) revealed: Policy: The Agency will establish an ongoing Agency wide, data driven program of quality assurance and performance improvement and maintain documentary evidence of its program. Purpose: To continually collect and analyze data to improve the Agency’s performance of clinical and other processes, specifically as follows: Continuously improve processes of patient care/services as well as outcomes of care. Communicate information internally and externally. Use a systematic approach to problem identification and resolutions. Conform to all applicable federal/state rules/regulations as well as accreditation home care standards. A review of the Home Health Agency’s policy titled “Performance Improvement Projects: (revised 2/2024) revealed: Policy: The Agency will conduct performance improvement projects. Purpose: To meet Medcare Conditions of Participation for conducting performance improvement projects. Procedure: 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. 3. The Agency should have one performance improvement project either in development, ongoing, or completed each year. 4. The Agency decides, based on the QAPI program activities and data, what projects are indicated and the priority of the projects.”