Mountain Crest Home Health

“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 review of quality improvement records, review of the “Meeting Minutes of the Governing Body,” and staff interview, it was determined the home health agency (HHA) failed to 1) develop, implement, and maintain an ongoing home health agency-wide data driven quality assessment and performance improvement (QAPI) program; 2) failed to measure, analyze and track quality indicators from all aspects of performance to enable the HHA to assess quality of care and HHA operations; 3) failed to document actions aimed at performance improvement and, after implementing those actions, measure it’s success and track performance to ensure that improvements are sustained; 4) failed to implement and maintain documentation of performance improvement projects (PIP) being conducted currently, the reasons for conducting these projects, and any measurable progress achieved on these projects; and 5) failed to ensure that an ongoing program for quality improvement was overseen by the agency’s governing body. Failure to develop an ongoing QAPI program had the potential to allow problems to remain unidentified and did not enable the HHA to reflect best practice patterns. This had the potential to affect the 99 patients who were currently receiving HHA services and all future home health patients. Findings include: 1. There was no documented evidence the HHA utilized data collection to examine all facets of the agency’s operation. Cross Reference G642. 2. There was no documented evidence patient services and activities that could impact patient/family care were evaluated as part of the QAPI program. Cross Reference G644. 3. There was no documented evidence the HHA used data collection to monitor the effectiveness and safety of services and quality of care. Cross Reference G656. 4. There was no documented evidence the HHA implemented and maintained documentation of performance improvement projects. Cross Reference G658. 5. There was no documented evidence the HHA’s governing body was responsible for ensuring that an ongoing program for quality improvement is defined, implemented, and maintained. Cross Reference G660.”

“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 review of the agency’s Emergency Preparedness Program Plan (EP) and interview, the Home Health Agency (HHA) failed to conduct a full-scale exercise every two years that was community based or an individual, facility based functional exercise, or a mock disaster drill or a tabletop exercise to activate the emergency plan and ensure that staff respond to emergencies as identified during training sessions and described in the “Emergency Preparedness Program Plan. This deficient practice had the potential to affect all 99 patients receiving services from the HHA. Findings include: Review of the “Emergency Preparedness Program Plan,” dated 01/15/24, revealed, “The Emergency Preparedness (EP) Program Plan was reviewed by the Professional Advisory Committee presented and approved by the governing body” and was signed by the Chief Executive Officer (CEO), Clinical Manager and Administrator. In the section of the plan titled, “Training,” it was recorded that the “Agency will conduct an annual disaster drill, with involvement from all agency staff, independent contractors, appropriate vendors and selected patients (up to a phone call away) to determine the effectiveness and efficiency of the current plan and any forms developed for use in a disaster.” Review of the emergency preparedness manual/loose leaf book revealed documentation of an agency-based onsite fire drill conducted on 01/19/24, with guidelines, procedures and considerations after the fire drill, a performance evaluation of the fire drill, and a summary of implemented interventions and corrective action. There was no other documentation of emergency preparedness exercises during 2023, 2024 or 2025. During an interview on 04/17/25 at 3:30 PM, the Clinical Manager confirmed the agency had not conducted any other emergency preparedness exercises. During an interview on 04/18/25 at 9:30 AM, the CEO confirmed there was one drill and stated, “We are planning on a day in June for another drill.””

“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 review of quality improvement records, interview, and policy review, the home health agency (HHA) failed to develop, implement, and maintain an ongoing, data driven quality assessment and performance improvement (QAPI) program which reviewed patient outcomes, patient safety and quality of care provided by the agency. Failure to develop an ongoing QAPI program had the potential to allow agency problems to remain unidentified and did not enable the HHA to reflect best practice patterns. This had the potential to affect 99 of 99 patients who were currently receiving HHA services and all future home health patients. Findings include: On 04/18/25 at 12:30 PM, documentation of the HHA’s quality program was requested. The documentation provided did not include information or data specifically related to the HHA program. The documentation failed to include indicators related to improved outcomes or care delivery, failed to reflect the type of data collection, and failed to demonstrate action taken by the HHA to improve agency performance. There was no documented evidence the HHA had developed a QAPI program that included patient assessment data elements, effectiveness of care delivery, adverse events, patient grievances, or HHA services and operations. During an interview on 04/18/25 at 1:30 PM, the Clinical Manager, who was responsible for the QAPI program, confirmed these findings and stated, “We look at clinical records but that is the extent of our quality program.” The Clinical Manager stated that “no meeting minutes had been documented that would reflect analysis of data for the purpose of implementing corrective action.” The Clinical Manager was unable to verbalize the agency’s quality processes, ongoing performance improvement projects, or examples of how data was collected, analyzed, and used to measure HHA effectiveness. Review of the agency policy titled, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” revised dated February 2024, revealed, “The Agency will establish an ongoing, Agency-wide, data-driven program of quality assurance and performance improvement and maintain documentary evidence of its program.””

“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 review of quality assessment and performance improvement (QAPI) records, staff interview, and review of home health agency (HHA) policy, the HHA failed to utilize quality indicator data, including measures derived from the OASIS (Outcome and Assessment Information Set). Failure to monitor the quality of services had the potential to allow a lack of effectiveness in this area to remain unidentified. This deficient practice had the potential to affect 99 of 99 patients who were currently receiving HHA services and all future home health patients. Findings include: A review of QAPI documents conducted on 04/18/25 at 12:30 PM revealed there was no documentation of an assessment of how the HHA performed in the areas of measures derived from the OASIS assessment such as controlling pain, improved patient mobility, wound healing, or other patient signs and symptoms after the implementation of HHA interventions. During an interview on 04/18/25 at 1:30 PM, the Clinical Manager who was responsible for the QAPI program, confirmed these findings and stated, “We don’t have a review of performance that includes any components from the OASIS.” The Clinical Manager was unable to verbalize the agency’s quality processes, ongoing performance improvement projects, or examples of how data was collected, analyzed, and used to measure HHA effectiveness. Review of the agency policy titled, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” revised dated February 2024, revealed, “The Agency program will 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. The program must utilize quality indicator data, including measures derived for OASIS were applicable.””

“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 review of QAPI (quality assessment and performance improvement) records, staff interview, and review of agency policy, the home health agency failed to implement and maintain documentation of performance improvement projects (PIPs) being conducted currently, the reasons for conducting these projects, and measurable progress achieved on these projects. Failure to develop performance improvement projects had the potential to allow agency problems to remain unidentified and did not enable the agency to reflect improved outcomes. This deficient practice had the potential to affect 99 of 99 patients who were currently receiving home health services and all future home health patients. Findings include: A review of QAPI documents conducted on 04/18/25 at 1:00 PM revealed there was no documentation of ongoing PIPs (performance improvement projects). During an interview on 04/18/25 at 1:30 PM, the Home Health Clinical Manager, who was responsible for the QAPI program, acknowledged this finding and stated, “We have not yet started any specific PIPs for the home health program. We may have done one last year, but I really can’t remember, I would have to check.” There was no documented evidence in the QAPI material presented that the home health agency had identified, implemented, and monitored specific performance improvement projects based on the results of quality monitoring as required. These findings were confirmed at the exit conference on 04/18/25 at 5:00 PM by the Home Health Chief Executive Officer. Review of the agency policy titled, “Performance Improvement Projects,” revised February 2024, revealed, “The Agency should have one performance improvement project either in development, ongoing or completed each calendar year. 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 review of quality improvement records, review of the “Meeting Minutes of the Governing Body,” staff interview, and review of agency policy, the home health agency (HHA) failed to ensure the HHA-wide quality assessment and performance improvement (QAPI) efforts addressed priorities for improved quality of care and patient safety, and that patient care delivery was evaluated for effectiveness. Failure to develop an ongoing QAPI program had the potential to allow agency problems to remain unidentified and did not enable the HHA to reflect best practice patterns. This had the potential to affect 99 of 99 patients who were currently receiving HHA services and all future home health patients. Findings include: On 04/18/25 at 12:30 PM, documentation of the HHA’s quality program was requested and reviewed. During this review, there was no documented evidence the HHA had developed a QAPI program that addressed priorities for improved quality of care and patient safety, or that patient care delivery had been evaluated for effectiveness. During an interview on 04/18/25 at approximately 1:10 PM, the Clinical Manager, who was responsible for the QAPI program, confirmed these findings and stated, “We look at medical records but that’s the extent of our quality program. We do have some meetings . . . I think maybe last year we had one, but we do not have meeting minutes. We sometimes meet with another home health agency here in the office and talk about this.” The Clinical Manager was unable to verbalize the agency’s quality processes, any ongoing performance improvement projects, or any examples of how data was collected, analyzed, and used to measure HHA effectiveness. On 04/18/25 at 2:30 PM, documentation of the HHA’s governing body activity was reviewed. The “Annual Meeting of the Members of the Corporation, Governing Body and Professional Advisory Committee,” dated 1/18/25, recorded, “The secretary announced that the next item of business is the presentation of reports . . . Reviews and update on Quality Assurance,” by the HHA Clinical Manager. No detail of the review or update given by the Clinical Manager was documented. During the exit conference on 04/18/25 at 5:00 PM, the Chief Executive Officer and Alternate Administrator acknowledged the discrepancy between the governing body minutes, which documented approval of the HHA’s QAPI program and the lack of QAPI data collection. The Alternate Administrator stated, “I understand now that our QAPI program has not yet been developed.” Review of the agency policy titled, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” revised February 2024, revealed, “The Governing Body is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented and maintained. The Governing Body must ensure that the program reflects the complexity of its organization and services.””

“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 staff in-service documentation, personnel file review, policy review, and staff interview, the home health agency (HHA) failed to ensure each home health aide completed at least 12 hours of in-service training during each 12-month period for 2 of 2 (Home Health Aide1, Home Health Aide 2) Home Health Aides that had been employed 12 months or longer. This deficient practice had the potential to affect the 99 patients who were currently receiving home health services and all future home health patients. Findings include: 1. Home Health Aide 1 - The employee’s date of hire was 08/25/2023. During review of the “In-Service Training” records for the period of 1/01/24 – 12/31/24, the total number of in-service hours documented for this aide equaled 10.0 hours. Review of the personnel file for this Home Health Aide revealed no additional documentation of in-service hours. 2. Home Health Aide 2 - This contracted employee’s date of hire was 12/23/23. During review of the “In-Service Training” records for the period of 1/01/24 – 12/31/24, the total number of in-service hours documented for this aide equaled zero hours. Review of the personnel file for this Home Health Aide revealed no additional documentation of in-service hours. During an interview on 04/17/25 at 4:30 PM, when the Clinical Manager was asked why HHa2 had no in-service training, the Clinical Manager stated “HHa2 is not really here that much.” During an interview on 4/17/25 at 4:40 PM, the Clinical Manager verified these findings and stated that no additional documentation of education was available for review and the 12-hour in-service requirement had not been met for the home health aides identified above. During an interview with Home Health Aide 1 on 04/18/25 at 10:10 AM, Home Health Aide 1 was asked how they met the required 12 hours of in-service training for each 12-month period. Home Health Aide 1 stated “I try to get it done when I go into the office, but I don’t get to the office very often. Honestly, I am not sure how many hours I had last year.” Review of the agency policy titled, “Home Health Aide Services and Training Program,” revised February 2024, revealed, “A home health aide must receive at least 12 hours of in-service training during each 12-month period.””

“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 record review, the Home Health Agency (HHA) failed to ensure at least one of the services provided to the patients was direct HHA employees. This had the potential to negatively affect 99 of 99 patients served by the agency and any future patients. Findings include: Review of the 04/18/25 “Staff List (list of employees that work for the agency),” including direct and contract/under arrangement, revealed there was no one service provided by direct employees. The number of contract employees was as follows: three of 10 nurses (two Registered Nurses and one Licensed Practical Nurse), eight of eight Physical Therapists (six Registered Physical Therapists and two Physical Therapy Assistants), two of two Occupational Therapists, one of one Speech Therapist and Medical Social Worker, and two of two Home Health Aides. Review of 10 employee human resource files revealed five employee’s files contained contract agreements with the Home Health as follows: Physical Therapist (PT)1 and PT2, Home Health Aide2, Licensed Practical Nurse2, and the Clinical Manager. Review of the agency’s “Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS), Home Health Agency Survey Report Form CMS 1572,” dated 04/18/25, revealed services provided as follows: skilled nursing: HHA staff and under arrangement; Physical Therapy: under arrangement; Occupational Therapy: under arrangement; Speech Therapy: under arrangement; Social Worker: HHA staff and under arrangement; and Home Health Aide: HHA staff and under arrangement. Policies were not available regarding the Home Health Agency’s requirement to provide at least one direct service, and this information was not addressed on the 01/09/24 and 01/18/25 meeting minutes from the “Annual Meeting of the Members of the Corporate Governing Body and Professional Advisory Committee” located in the “Governing Body” loose leaf notebook. During an interview on 04/18/25 at 11:35 AM, the Office Manager and Chief Executive Officer (CEO) revealed they asked the prospective employees if they wanted a W2 (a direct worker whose employer-Mountain Crest Home Health deducts taxes from employees’ wages and reports annual earnings to the Internal Revenue Service) or a 1099 form (independent contractor). The Office Manager indicated they contacted a service company when services were needed at the agency. The CEO confirmed that the agency did not have at least one service that had direct employees. They stated they would request Certified Nursing Assistants (CNAs)/Home Health Aides to be direct agency employees.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview, record review, and review of agency policy, the Home Health Agency (HHA) failed to ensure the plan of care, including evaluations, assessments, goals, and interventions, were complete for three of seven patients (Patients (P) 1, P2, and P5) whose records were reviewed. This had the potential to place all residents at risk for negative outcomes. Findings include: 1. On 04/16/25, a review of P1’s electronic medical record (EMR) titled, “Home Health Certification and Plan of Care,” dated 09/11/24, revealed no documentation of P1’s diagnoses, primary reason for home health services, mental status, functional limitations, vital signs, orders for discipline and treatment, problems, goals, or interventions. There was a statement on the form located in the section titled, “Progress toward goals as of certification date (11/08/24): No Care Plans.” It was recorded the assessment and plan of care had been “Reviewed, esigned (electronic signature) by: [Registered Nurse (RN)2]” on 11/08/24 and sent on 11/11/24. Review of P1’s “Outcome and Assessment Information Set (OASIS, a comprehensive assessment regarding clinical status, functional status, and service needs),” dated 01/08/25, was blank. It was recorded on the assessment, “visit time in/out: 01/08/25, 13:00 - 13:30 (1:00 PM to 1:30 PM).” During an interview on 04/16/25 at 3:20 PM, the Clinical Manager confirmed P1’s plan of care was not complete. The Clinical Manager stated there were goals listed in the OASIS assessment dated 09/11/24, but there were no interventions. On 04/16/2024 at 4:20 PM, the Clinical Manager stated, “The software removed the plan of care. We were not informed. It changed to AI [artificial intelligence]. Staff were to select the goals and interventions; they [name of software company] updated the software. Moving forward we will coordinate with them [name of software company]. They will tell us how to go about it. So that is the problem they created.” On 04/17/25, review of P1’s “Home Health Certification and Plan of Care,” dated 09/11/24, and “OASIS,” dated 01/08/25, revealed the documents had been completed. During an interview on 04/18/25 at 9:30 AM, the Chief Executive Officer (CEO) stated, “We had issues (with the software); they [staff] completed charting, but it wasn’t there.” During a telephone interview on 04/18/2024 at 2:15 PM, Registered Nurse (RN)2 stated there had been a problem with the electronic charting software. RN2 stated, “During the past month, the problem is with the software, which is why documentation is always delayed. I could not document notes or OASIS. We always complain. I write everything including vital signs, transfer the information and always have a copy. With no documentation on the plan of care, the question may arise, did the visit happen?” 2. Record review revealed P2 was admitted to the home health agency on 01/10/25 with the significant diagnoses of cirrhosis of liver and diabetes mellitus. P2 was admitted for skilled nursing and home health aide services. During review of the plan of care, dated 01/10/25, it was noted that the section titled “Orders for discipline and treatment,” was blank other than visit frequency orders. The plan of care failed to include any orders for treatment or monitoring of P2’s cirrhosis or diabetes mellitus. The plan of care failed to include any measurable goals or desired outcomes other than “Discharge when stable.” 3. Record review revealed P5 was admitted to the home health agency on 03/21/25 with the significant diagnoses of infection following procedure with surgical site, traumatic brain injury and diabetes mellitus. P5 was admitted for skilled nursing, physical therapy, occupational therapy, and speech therapy. During review of the plan of care, dated 03/21/25, it was noted that the section titled “Orders for discipline and treatment,” was blank other than visit frequency orders. The plan of care failed to include any orders for treatment or monitoring of P5’s surgical wound or diabetes mellitus. The plan of care failed to include any measurable goals or desired outcomes other than “Discharge when stable.” During an interview on 4/17/25 at 3:00 PM, the Clinical Manager was asked why the areas of treatment and goals were incomplete on the plans of care for P2 and P5. The Clinical Manager responded “I don’t know… I will have to check.” Review of the agency’s policy titled, “Plan of Care, “ revised 02/2024, revealed, “. . . 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 measurable outcomes that the Agency anticipates will occur because of implementing and coordinating the plan of care . . .””

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on staff interview, policy review, and review of quality improvement records, the home health agency (HHA) failed to take actions aimed at performance improvement and, after implementing those actions, objectively measure the success and track performance to ensure improvements were sustained. Failure to develop an ongoing QAPI (quality assessment performance improvement) program had the potential to allow agency problems to remain unidentified and did not enable the HHA to reflect best practice patterns. This deficient practice had the potential to affect 99 of 99 patients who were currently receiving HHA services and all future home health patients. Findings include: On 04/18/25 at 12:30 PM, documentation of the HHA’s quality program was requested and reviewed. The documentation presented failed to include indicators related to improved performance outcomes or care delivery, failed to reflect the type of data collection, including adverse event tracking, and failed to demonstrate action taken by the agency to improve HHA performance. During an interview on 04/18/25 at 1:15 PM, the Clinical Manager who was responsible for the QAPI program, confirmed these findings. The Clinical Manager stated, “We haven’t developed an in-depth quality program.” During this interview, the Clinical Manager verified the HHA had not documented any quality activity that would reflect analysis of data for the purpose of implementing corrective action. The Clinical Manager stated, “We haven’t incorporated data, statistics, or trending into our quality program.” Review of the agency policy titled, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” revised February 2024, revealed, “The Agency’s performance improvement activities will: Focus on high risk, high volume, and problem prone areas . . . lead to an immediate correction of ay identified problem that directly or potentially threaten [sic] the health and safety of patients.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure a system was in place for timely submission of “Home Health Aide – Progress Visit Note” for one of seven patients’ (Patients(P) 1) whose records were reviewed. This failed practice placed P1 at risk for negative outcomes. Findings include: Review of P1’s “Physician Order,” dated 09/11/24, included diagnoses that included hypertension, hyperlipidemia, and hypothyroidism. Review of P1’s “Home Health Aide (HH Aide) Care Plan,” dated 09/11/24, revealed the HH Aide was to provide vital signs every visit, bath per request, comb hair per request, foot care, lotion per request, assist with dressing, skin care/check pressure areas every visit, linen change, perineal care, make bed per request, turn/reposition per request, assist with ambulation, assist with transfer, offer fluids, record intake output, range of motion exercises, medication reminder, and toilet/bedpan/commode with every visit. Review of P1’s “Outcome and Assessment Information Set (OASIS),” dated 03/07/25, revealed HH Aide services were to be provided two times a week for eight weeks. Review of P1’s electronic medical record (EMR) calendar of services, revealed P1’s “Home Health Aide – Progress Visit Note” for 04/08/25 and 04/11/25 were blank. There was no documentation of services provided on each visit. The documents recorded the name of HH Aide 1. During an interview on 04/16/25 at 3:20 PM, the Clinical Manager stated, “They [staff] should do it [document on the form] as soon as they see the patient or within one to three days. They use their phone, an app on their phone.” During an interview at a home visit of P1 on 04/18/25 at 10:00 AM, HH Aide 1 was observed providing services for P1. HH Aide 1 did not recall if the progress visit notes dated 04/08/25 and 04/11/25 were completed. HH Aide 1 stated the HH Aide must save the form before signing out, and the patient also signs that there was a visit by the HH Aide. On 04/18/25 at 10:55 AM, the Chief Executive Officer confirmed the late entry of the 04/08/25 and 04/11/25 “Home Health Aide – Progress Visit Note” forms. Review of the agency’s policy titled, “Timely Submission of Patient Identification, revised February 2024, revealed, “. . . The agency will ensure the timely and proper submission of patient documentation . . . Itineraries, with all visit reports attached, must be submitted the next scheduled workday not exceeding three (3) business days. All patients visit reports from contract personnel must be submitted within three (3) business days from the date of the visit . . .””