Providence Home Health Agency, Inc.

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on a review of policies/procedures, requests for QAPI (quality assessment performance improvement) documentation, and interviews with the alternate Administrator, it was determined that the facility failed to develop, implement, evaluate, and maintain an effective, ongoing, agency-wide, data-driven QAPI program.; failed to provide documentation showing the agency’s executive responsibilities for the definition, implementation and maintenance of a program for quality improvement and patient safety. This CONDITION is not met as evidenced by: Cross Reference: 484.65(a)(1)(2) Program Scope (Tag 642): No documentation provided of an agency wide QAPI program, to include but not limited to, the program scope. 484.65(b)(1)(2)(3) Program Data (Tag 644): No documentation provided of an agency wide QAPI program, to include but not limited to, program data. 484.65(c) Program Activities (Tag 646): No documentation provided of an agency wide QAPI program, to include but not limited to, the agency program activities. 484.65(c)(1)(i) High risk, high volume, or problem prone areas (Tag 648): No documentation provided of an agency wide QAPI program, to include but not limited to, high risk, high volume, or problem-prone areas. 484.65(c)(1)(ii) Incidence, prevalence, severity of problems (Tag 650): No documentation provided of an agency wide QAPI program, to include but not limited to, incidence, prevalence, and severity of problems. 484.65(c)(2) Track adverse events (tag 654): No documentation provided of an agency wide QAPI program, to include but not limited to, tracking adverse patient events. 484.65(c)(3) Improvements are sustained (Tag 656): No documentation provided of an agency wide QAPI program, to include but not limited to, ensuring improvements are sustained. 484.65(e)(1)(2)(3)(4) Executive Responsibilities for QAPI (Tag 660): No documentation provided of an agency wide QAPI program, to include but not limited to, defining agency executive responsibilities. The cumulative effect of these systematic problems resulted in the home health agency’s inability to ensure the provision of quality healthcare.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on a review of the agency Emergency Preparedness Plan and an interview with the agency Administrator, agency failed to ensure the plan was reviewed and updated at least every 2 years, for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1). Agency policy was reviewed on January 24, 2024 at approximately 1:00 p.m. ‘Emergency Operations Plan and Policies’ ‘Procedure’ section (1) states “The agency complies with all applicable federal, state, and local emergency preparedness requirements.” Section (2) states “The agency has established and maintains an emergency preparedness program that meets all requirements.” A review of the agency Emergency Preparedness Plan conducted on January 23, 2024 at approximately 11:45 a.m. revealed the following: EP #1: No documentation provided of the agency Emergency Preparedness Plan being reviewed and updated at least every 2 years. Per the agency alternate Administrator on 1/23/24 at approximately 11:55 a.m., the emergency preparedness plan has not been updated since the plan was developed in 2017. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] 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:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on a review of the agency Emergency Preparedness Plan and an interview with the agency Administrator, agency failed to ensure policies and procedures address informing State and local emergency preparedness officials about homebound patients in need of evacuation from their residences at any time due to an emergency situation for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1). Agency policy was reviewed on January 24, 2024 at approximately 1:00 p.m. ‘Emergency Operations Plan and Policies’ ‘Procedure’ section (1) states “The agency complies with all applicable federal, state, and local emergency preparedness requirements.” Section (2) states “The agency has established and maintains an emergency preparedness program that meets all requirements.” A review of the agency Emergency Preparedness Plan conducted on January 23, 2024 at approximately 11:45 a.m. revealed the following: EP #1: No documentation provided of the agency Emergency Preparedness Plan including policies/procedures to inform State and local emergency preparedness officials about homebound patients in need of evacuation from their residences at any time due to an emergency situation. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on a review of the agency Emergency Preparedness Plan and an interview with the agency Administrator, agency failed to ensure policies and procedures address the use of volunteers or other emergency staffing strategies in an emergency for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1). Agency policy related to the use of volunteers or other emergency staffing strategies in an emergency was reviewed on January 24, 2024 at approximately 1:00 p.m. ‘Emergency Operations Plan and Policies’ ‘Procedure’ section (1) states “The agency complies with all applicable federal, state, and local emergency preparedness requirements.” Section (2) states “The agency has established and maintains an emergency preparedness program that meets all requirements.” A review of the agency Emergency Preparedness Plan conducted on January 23, 2024 at approximately 11:45 a.m. revealed the following: EP #1: No documentation provided of the agency Emergency Preparedness Plan addressing the use of volunteers or other emergency staffing strategies in an emergency. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“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 a request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, the program scope, for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, the program scope. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“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 a request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, program data, for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, program data. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA’s performance improvement activities must-- This Standard is not met as evidenced by: Based on a request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, agency program activities, for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, the agency program activities. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“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 a request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, tracking adverse patient events, for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, tracking adverse patient events. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. 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 request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, defining agency executive responsibilities, for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, defining agency executive responsibilities. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“Therapy services determine eligibility CFR(s): 484.55(b)(3) When physical therapy, speech-language pathology, or occupational therapy is the only service ordered by the physician or allowed practitioner, a physical therapist, speech-language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. The occupational therapist may complete the comprehensive assessment if the need for occupational therapy establishes program eligibility. This Element is not met as evidenced by: Based upon review of policy, clinical records (CR) and an interview with the agency Administrator, the agency failed to ensure a qualified therapist (registered and/or licensed by the State in which they practice) should perform the comprehensive assessment for therapy services ordered for one (1) of seven (7) CR reviewed. (CR#2) Agency policy was reviewed on January 24, 2024 at approximately 1:00 p.m. Policy “Patients receiving rehabilitation services (PT, OT and/or SLP) will have appropriate assessments, evaluations, care planning, reassessments and established outcomes performed.” A review of CRs was conducted on January 24, 2022 between approximately 9:15 a.m. and 1:00 p.m. The patients start of care (SOC) is listed below. CR#2 (SOC 1/02/24):According to Home Health certification and plan of care for the certification period of 1/2/2024-3/1/2024, the Physical Therapist (PT) order to start the week of 1/2/2024 is one week one (1w1). No documentation of a PT visit made during week one (1). No documentation of a PT visit made week during two (2) 1/7/2024-1/13/2024. On week three (3) 1/14/2024-1/20/2024, a physical therapist assistant (PTA) made a visit on 1/15/24 without documentation of an initial comprehensive visit made from the PT. On 1/20/2024, the PTA made another visit without documentation of an initial visit made by the PT. No documentation of any signed verbal or written orders from the physician. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to reconcile medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in one (1) of the three (3) home visits. (CR#3) Agency policy was reviewed on January 24, 2024 at approximately 1:00 p.m. A policy titled “Medication Reconciliation, The Agency will reconcile patient’ s medications at time of admission and on an ongoing basis” states, “PROCEDURE 1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. Any discrepancies will be reconciled by a RN with the patient’s physician. Discrepancies include duplications, omissions, changes, contraindications and/or unclear information. The Agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by Agency staff and staff acting on behalf of the Agency. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.....” A home visit on January 23,2024 at approximately 10:30am to 11:30 am and a review of CR was conducted on January 24, 2024 between approximately 9:15 a.m. and 1:00 pm revealed: CR#3 SOC 09/26/23: during an Everyday Community Resources residential group home visit, reviewed the Medication Administration Record. Current medication list in home as follows: ZINC OXIDE OINT 20% APPLY TOPICALLY TO AFFECTED AREA AS NEEDED FOR IRRITATION OR DRY 07/28/2023. This medication is not on agency med profile. ACETAMINOPHE Tab 325MG TAKE 2 Tablets By mouth (650MG)EVERY 6 HOURS AS NEEDED FOR MILD PAIN MODERATE-SEYERE_PAIN 09/22/2023. This medication is not on agency med profile. LIDOCAINE OINT 5% APPLY TOPICALLY TO AFFECTED AREA AS NEEDED FOR MILD PAIN 10/25/2023. This medication is not on agency med profile. LOPERAMIDE CAP 2MG TAKE 1 CAPSULE BY MOUTH TWICE A DAY AS NEEDED FOR DIARRHEA PRN,11/15/23. This medication is not on agency med profile. THICK-IT POW ORIGINAL GIVE 1 SCOOP BY MOUTH AS NEEDED TO HONEY THICK LIQUID CONSISTENCY NOT A PRN - DAILY USE, 07/25/2022. This medication is not on agency med profile. METOPROL TAB 25 MG TAKE 1/2 Tablet BY Mouth DALY HIGH BLOOD PRESURE, CALCIUM ANTACID 500 MG CHEW 1 TABLET BY Mouth TWICE DAY. The dosage is 600mg on the med profile. POT CHLORIDE TAB 10MEQ ER 12/13/23AM TAKETABLET BY MOUTH DAILY POTASSIUM DEFECIENCY, 12/13/2023 SERTRALINE TAB 100MG Sub For: ZOLOFT TAKE 1 TABLET BY MOUTH DAILY MOOD DISORDER 12/05/23, TRAZODONE TAB 50MG TAKE 1/2 TABLET BY MOUTH (25MG) TWICE A DAY12/05/23. This medication is not on agency med profile. TRIAD HYDROPHILIC WOUND GEL Sub For: HYDROPHILIC WOUND GEL APPLY TOPICALLY TO AFFECTED AREA FIVE TIMES A DAY 09/29/23. This medication is not on agency med profile. NYSTATIN CREAM 100000 APPLY TOPICALLY TO AFFECTED AREA TWICE0 9/29/23. This medication is not on agency med profile. OLANZAPINE TAB 10MG Sub For: ZYPREXA TAKE 1 TABLET BY MOUTH DAILY 12/05/23. The dosage is 5mg on the med profile. PANTOPRAZOLE TAB 40MG Sub For: PROTONIX TAKE 1 TABLET BY MOUTH DAILY 12/04/2023. VITAMIN D3 TAB 50MCG Sub For: RUGBY VITD3 50MCG TAKE 1 TABLET BY MOUTH EVERY MORNING 07/26/2022. XARELTO TAB 20MG TABLET BY MOUTH DAILY 08/04/2023. ENSURE PLANT LIQ VANILLA DRINK 1 CAN (237 ML) TWICE A DAYNUTRITIONAL SUPPORT. This medication is not on agency med profile. ERYTHROMYCIN OIN 5MG/GM APPLY SMALL AMOUNT INTO BOTH EYES AT NIGHT. FeRrouS sulF tAB 324MG EC Sub For: FEOSOL TAB TAKE 1 TABLET BY MOUTH DAILY BEFORE BREAKFAST FUROSEmIDE TAB 20MG Sub For: LASIX TAKE 1 TABLET BY MOUTH DAILY FLUID RETENTION. LEVOTHYROXIN TAB 88MCG Sub For: SYNTHROID TAKE 1 TABLET BY MOUTH DAILY12/04/23. CR#3 agency medication profile list revealed list as follows: Calcium carbonate tablet, chewable 600 mg daily oral. The dosage is 500mg in the home Cholecalciferol(vitamin D3) capsule 50 mcg daily oral Erythromycin ophthalmic(Ilotycin) ointment 0.5% as prescribed ophthalmic Ferrous sulfate(ferrous sulfate (65 mg elemental iron)) delayed 325 mg daily oral Furosemide tablet 20mg daily oral Levothyroxine tablet 88 mcg (0.088 mg) daily oral Lisinopril tablet 5 mg daily oral. This medication is not in the home. Metoprolol (metoprolol succinate) tablet, extended release 25 mg half a tab daily oral Niacin tablet, extended release 500 mg nightly oral- This medication is not in the home. OLANZapine tablet 5 mg nightly oral- The dosage is10mg in home. Dose changed 10/05/2023) Pantoprazole delayed release tablet 40 mg daily oral Potassium chloride tablet, extended release 10 mEq daily oral Rivaroxaban tablet 20 mg nightly oral Sertraline tablet 50 mg 2 tabs nightly oral SN (skilled nurse) revisit note for 12/28/2023 in the “narrative/teaching/care plan” section states, “No med changes.” “Medication assessment” section of the revisit note states, Drug Regimen Review- List problems identified: n/a” An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings. Repeat deficiency.”

“High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This Element is not met as evidenced by: Based on a request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, high risk, high volume, or problem-prone areas, for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, high risk, high volume, or problem-prone areas. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“Incidence, prevalence, severity of problems CFR(s): 484.65(c)(1)(ii) (ii) Consider incidence, prevalence, and severity of problems in those areas; and This Element is not met as evidenced by: Based on a request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, incidence, prevalence, and severity of problems for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, incidence, prevalence, and severity of problems. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“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 a request to review the agency quality and performance improvement (QAPI) program and an interview with the agency Administrator, agency failed to ensure the development of an agency wide QAPI program, to include but not limited to, ensuring improvements are sustained, for one (1) of one (1) QAPI program documentation requests (QAPI# 1). Agency policy related to the QAPI program was requested on January 24, 2024 at approximately 9:15 a.m. No policy provided. A request to review the agency QAPI program was made on January 24, 2024 at approximately 9:15 a.m. QAPI #1: No documentation provided of an agency wide QAPI program, to include but not limited to, ensuring improvements are sustained. An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of agency policy, clinical records, and an interview with the agency Administrator, agency failed to send a discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (HHA) (if any) within five (5) business days of the date of the order for discharge from the responsible physician and/or failed to include all (5) of the required discharge summary elements, per policy, for three (3) of three (3) discharged clinical records (CR) reviewed (CR#4, CR#6, CR#7). Agency policy was reviewed on January 24, 2024 at approximately 1:00 p.m. ‘Discharge Summary’ ‘Policy’ states “A Discharge Summary will be completed for all patients discharged from the agency.” ‘Procedure’ section (1) states A Discharge Summary form will be completed by the skilled nurse, medical social worker and/or therapist. The Discharge Summary will include, but is not limited to: Discharge date, reason for discharge, status of problems identified throughout the course of care, patient’s overall status, and a summary of care or services provided.” (2) states “A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient.” (3) states “The original Discharge Summary form from each service will be filed in the medical record.” A review of CRs was conducted on January 24, 2022 between approximately 9:15 a.m. and 1:00 p.m. The patients start of care (SOC) is listed below. CR#4 SOC 07/26/23: Patient discharged from agency on January 9, 2024. Documentation provided of agency obtaining a verbal order from the physician on 01/09/24 (Discharge Summary form). no documentation provided of the Discharge Summary being sent to the physician. CR#6 SOC 11/13/23: Patient discharged from agency on December 29, 2024. Documentation provided of agency obtaining a verbal order from the physician on 12/29/23 and sending a Discharge Summary to the physician on 01/22/24. The Discharge Summary did not include all (5) required elements, per policy. The ‘Summary Analysis’ only stated “Client discharged with all goals met.” CR#7 SOC 10/27/23: Patient discharged from agency on November 6, 2023. Documentation provided of agency obtaining a verbal order from the physician on 11/06/23 and sending a Discharge Summary to the physician on 11/07/23. The Discharge Summary did not include all (5) required elements, per policy. The ‘Summary Analysis’ only stated “Client discharged with all goals met.” An interview conducted with agency Administrator on January 24, 2024 at approximately 1:45 p.m. confirmed the above findings. Repeat deficiency.”