Intrinsic, Inc.

“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 agency policy, documentation, and staff (EMP) interview, the agency failed to conduct distinct performance improvement projects annually that reflected the scope, complexity, and past performance of the HHA’s services and operations, and failed to document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects for the years 2022, 2023, and 2024. Review of agency policy on June 4, 2025, at 10 a.m. showed, “QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PLAN (QAPI) Intrinsic, Inc. shall establish a Quality Assurance and Performance Improvement plan to continuously measure, assess, and improve the performance of clinical and other processes. This plan will be based on the organization’s mission and goals and designed to improve client outcomes and the perceptions of clients/families about the quality and value of services. ... PURPOSE ... To identify areas for improvement in the quality of care, treatment and services. To improve client and agency outcomes through a coordinated collaborative approach to assessing and improving organizational performance. To evaluate all areas of concern and implement plans to resolve the issues. OBJECTIVE OF THE PROGRAM To assess and evaluate the quality and appropriateness of client care services provided, and satisfaction of clients and families. ... To identify deviations from agency and professional standards and pursue improvement opportunities by assessment, planning and evaluation. To identify, address, track and resolve problems in client care services and satisfaction to insure resolution and/or improvement. ... To support the organization’s process improvement through data collection and outcome measurement in compliance with OASIS Data Collection required by CMS. To reduce factors that may contribute to unanticipated adverse events and/or outcomes ... 1. The development of a performance improvement plan will be guided by the mission, vision and strategic goals of the organization. Additional activities for performance improvement will be prioritized by the agency’s management team. Program will reflect participation by all services and levels of staff; and will Subscribe to compliance with internal and external standards including the Medicare Conditions of Participation and JCAHO/CHAP/ACHC performance improvement standards. 2. Data will be collected to allow the agency to monitor its performance. Data collection will be prioritized based on the organization’s mission, care services provided, and populations served. Data that may be used for data collection include the following: a) Staff perception of risks to individuals and suggestions for improving safety for clients. b) Utilization of services. c) Staff opinion and needs. d) Adverse events/outcomes of processes or services, e) Infection control surveillance and reporting. f) The needs, expectations and satisfaction of individuals and organizations served. g) Perceptions of care, treatment and services including: How well the agency meets these needs and expectations. How the organization can enhance client safety and improve outcomes. Effectiveness of programs in responding to specific concerns such as pain management and medication management. i) Client diagnosis and demographics. j) Environmental conditions of the organization or clients. 3. The activities will meet the needs of clients, Staff and others and will unite new and existing improvement activities into the agency’s system wide approach. 4. Data will be systematically collected to measure process and outcome. 5. Data will be assessed to: a) Identify current level of performance. b) Evaluate the stability of the processes. c) Identify effectiveness of communication systems. d) Identify areas to be improved. e) Identify strategies to stabilize or improve processes. f) Evaluate whether outcomes were achieved. 6. This process will encourage the following behaviors/activities: a) Recognizing and acknowledging the risks and anticipated adverse events/outcomes. b) Initiating actions to reduce risks and outcome. c) Reporting internally on risk reduction initiatives and their effectiveness. d) Minimizing blame or retribution for involvement in an unanticipated adverse event/outcome. e) Investigating factors that contribute to unanticipated adverse events. f) Sharing knowledge within the organization and with other organizations. 7. Intensive assessment will be completed when undesirable patterns or trends in performance are detected or important sentinel events are identified. 8. The plan will target the performance of existing processes and outcomes and identify/design new processes based on priorities, standards and resources. ... 11. Information is communicated to all departments when they are impacted by Performance Improvement activities or findings that may affect the agency and its goal of providing quality care in an efficient and effective manner. 12. Performance improvement activities, minutes, reports, correspondence are considered to be confidential and privileged. Some information may be disseminated on a “need to know” basis as required to meet regulatory requirements and other review organizations. This would be approved by the Administrator/Governing Body. 13. The QAPI Plan is evaluated at least annually and is incorporated into the annual agency evaluation required by CMS.” Review of agency documentation with EMP1 (administrator) on June 4, 2025, at 11 a.m. revealed “INTRINSIC, INC QUARTERLY CLINICAL RECORD REVIEW AND QUALITY ASSURANCE REVIEW” for 2024, 2023, and 2022. The statistical data showed agency had identified problems with clinical and agency quality indicators to include patient falls, infections, a decrease in referrals, staffing issues, and a chronically low census. Specifically, the agency recorded patient falls for the 1st, 2nd, and 3rd quarters of 2024; UTIs (urinary tract infections) for the 1st, 2nd, 3rd quarters and five (5) falls during the 4th quarter of 2023; UTIs for the 1st, and 2nd (13 this quarter alone) quarters of 2022; and falls for the 1st (9 falls), 2nd (3 falls), 3rd (13 falls), and 4th (8 falls) quarters of 2022. Further review of agency documentation on June 4, 2025, at 12 p.m. did not show agency developed distinct performance improvement projects concerning problems identified during quarterly meetings to include falls, infections, low census, low referrals, and staffing. An interview with EMP1 at the time of review confirmed above findings.”