Ken-Care Home Health Agency

“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 a review of home health agency (HHA) documents and an interview with the Home Health Agency Director (Dir), the agency failed to provide evidence that at least one performance improvement project was conducted annually. Findings include: The quality assessment and improvement program and data for 2022 and 2023, reviewed March 19, 2024 at 12:00 PM, and again on March 20, 2024 at 10:00 AM did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023. Governing Body Meeting Minutes, dated May 22, 2023 and May 22, 2022, reviewed March 19, 2024 at 1:00 PM and again on March 20, 2024 at 9:30 AM, did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023. Annual Program Evaluation Reports, dated May 12, 2023 and May 12, 2022, reviewed on March 19, 2024 at 12:45 PM, did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023. Professional Advisory Committee Meeting Minutes, dated March 6, 2023 and March 22, 2022, reviewed on March 19, 2024 at 12:30 PM, did not contain any evidence that a performance improvement project was identified and conducted in 2022 or 2023. An interview on March 19, 2024 at 12:30 PM and again on March 20, 2024 at 10:30 AM with the Dir revealed that the HHA had not identified and conducted any performance improvement projects in 2022 or 2023. An interview with the Director and the Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.”

“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 a review of governing board meeting minutes, the annual program evaluation, the professional advisory committee meeting minutes, clinical record review indicators, and an interview with the Director and Administrator, the agency did not demonstrate that the governing body addressed priorities for improved quality of care and patient safety, focused on indicators related to improved outcomes, ensured the effectiveness of the improvement efforts, and established clear expectations for the implementation and maintenance of patient safety. Findings include: Governing Body Meeting Minutes, dated May 22, 2023 and May 23, 2022, reviewed March 19, 2024 at 1:00 PM and again on March 20, 2024 at 9:30 AM, contained the same language each year as follows: “Be it further resolved that the Ken-Crest Services Board of Directors approves the program evaluation.” Annual Program Evaluation Reports, dated May 12, 2023 and May 12, 2022, reviewed on March 19, 2024 at 12:45 PM contained the same language each year as follows: “Mechanisms are in place to collect pertinent data to assist in the evaluation process and to monitor the care provided to the children through quarterly clinical record reviews and continuing review of clinical records each 62-day period. Children make progress, despite challenging obstacles, in the medical, developmental and educational domains. Children have: 1) weaned from ventilators, oxygen and feeding tubes...; 2) several of the children have been decannulated (tracheostomy tube removed); 3) reached developmental milestones as a result of a variety of therapeutic services...; 4) been discharged to competent trained caregivers. These impressive outcomes are, in large measure, a reflection of our staff’s commitment to excellence.” Professional Advisory Committee Meeting Minutes, dated March 6, 2023 and March 22, 2022, reviewed on March 19, 2024 at 12:30 PM contained the same language each year as follows: “Quality Assurance Chart Review: Chart reviews for therapy services were completed by discipline-specific independent consultants for the past four quarters. During the reviews for the past couple of quarters, no issues were identified.” Clinical Record Reviews, conducted quarterly in 2022 and 2023, were reviewed on March 19, 2024 at 12:00 PM. The performance indicators contained in the review were as follows: “order present on plan of care; initial evaluation signed by physician and discipline; initial evaluation includes modalities/interventions/treatments; visit documented in clinical notes with signature and dates; frequency of visits complies with physician order; monthly review of treatment objectives present; documented physician notification of missed therapy visit; documented communication with members of team or family at least monthly; and discharge summary completed, if indicated.” Data from the clinical record reviews was collected individually per patient each quarter. There was no evidence that the data was compiled so that the effectiveness of the indicators/performance, in aggregate, could be evaluated, nor was there evidence that a change in indicators was considered given that the above-referenced Professional Advisory Committee meeting minutes noted “no issues” related to the same set of performance indicators reviewed over a two-year period. Outcome measures were not established. There was no evidence of data collection related to outcomes documented in the quality assessment/performance improvement program, or the annual program evaluation reports for 2022 and 2023. There was no data to support that the governing body focused on indicators related to improved outcomes, the effectiveness of improvement efforts, nor was there evidence that the governing body provided clear expectations related to the implementation and maintenance of patient safety. An interview with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on a home visit (HV) observation, review of agency policy and procedure, and an interview with the Clinical Services Coordinator, the agency failed to assure that acceptable standards of practice for infection control/prevention were maintained. One (1) of three (3) HV observations did not meet the requirement: PF# 5 (HV #3). Findings include: A review of the home health agency’s (HHA) Policy and Procedure Infection Control - Facility Procedure #1, conducted on March 18, 2024 at 2:30 PM, reads in part “Purpose: To assure that both children and staff are as safe as possible from the risk of infection. Policy: Ken-Crest will do everything possible to maintain a safe environment in the residences and to eliminate or minimize conditions and practices that could expose children, visitors, or employees to injury or harm of any kind.” A home visit observation took place on March 19, 2024 between 2:00 PM and 2:30 PM. The home visit was observed by two (2) surveyors, the home health agency’s clinical services coordinator, and a registered nurse (RN1) associated with the agency’s Intermediate Care Facility (ICF) licensure. A physical therapist (PT) was observed to be providing treatment to a medically-complex, technologically-dependent child who was lying flat on a mat which was on the floor. During the course of the PT treatment, RN#1 was standing next to the mat observing the treatment. RN#1 then proceeded to walk on the mat that the child was lying on, with shoes on, in order to change the channel on the television (TV), and then walked on the mat again in order to return to his/her original position. There was no floor clearance to reach the TV since the position of the mat, immediately adjacent to various pieces of equipment, precluded the ability to walk directly on the floor. There was no attempt to clean the mat with a disinfectant or sanitizing agent after walking on it. An interview conducted with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on a review of personnel files, and an interview with the director, there was no evidence that staff received annual infection control education. Three (3) of six (6) personnel files did not meet the requirement: PF#4, PF#5, and PF#6. Findings include: A review of personnel files was conducted on March 18, 2024 starting at 11:00 AM. The start date (SD) is indicated below. PF#4 SD 11/10/2020 did not contain evidence that annual infection control education was provided in 2022 or 2023. PF#4 is a contracted staff member. PF#5 SD 04/17/2017 did not contain evidence that annual infection control education was provided in 2022 or 2023. PF#5 is a contracted staff member. PF#6 SD 11/13/2007 did not contain evidence that annual infection control education was provided in 2022 or 2023. PF#6 is a contracted staff member. An interview conducted with the Director and Administrator on March 20, 2024 confirmed the above findings.”

“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 a review of personnel files (PF), contractual arrangements, email correspondence, therapist orientation checklist, and an interview with the director, the home health agency (HHA) failed to assure that the HHA employed qualified personnel. Three (3) of six (6) PF’s reviewed did not meet the requirement: PF#4, PF#5, and PF#6. Findings include: A review of the contractual arrangement for therapy services (physical and occupational therapy) provided by Austill Rehabilitation Services (ARS) dated March 24, 2023 was conducted on March 18, 2024 at approximately 1:00 PM. The contract reads in part, “The Agency (Ken-Crest Services) has the ultimate responsibility for the administration or supervision of services provided.” An email exchange on February 9, 2024 at 9:08 AM between the HHA and ARS, reviewed on March 18, 2024 at approximately 1:15 PM, reads in part from ARS: “When PF#5 and PF#6 switched companies from Theraplay to Austill, they became independent contractors and we do not do performance evals for independent contractors, so they would not have anything for the years you mentioned - 2022, 2023, or 2024.” The Therapist Orientation Checklist, reviewed on March 18, 2024 at approximately 1:30 PM, contained the following information to be discussed/reviewed: “Job Description.” A review of personnel files was conducted on March 18, 2024 starting at 11:00 AM. The start date (SD) is indicated below. PF#4 SD 11/10/2020 did not contain evidence of a signed job description at any time, nor was there evidence of annual performance evaluations for 2022 and 2023. PF#4 was a contracted staff member. PF#5 SD 04/17/2017 did not contain evidence of a signed job description at any time, nor was there evidence of annual performance evaluations for 2022 and 2023. PF#5 was a contracted staff member. PF#6 SD 11/13/2007 did not contain evidence of a signed job description at any time. PF#6 was a contracted staff member. An interview conducted with the Director and Administrator on March 20, 2024 starting at 12:00 PM confirmed the above findings.”