Progressive Home Health Agency

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 34 of 2305 assessments processed for the time-period reviewed of 6/1/2024 to 6/2/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: In a review of the HHA Error Summary Report for the time period of 6/1/2024 to 6/2/2025, the report identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 34 assessments and the percentage of assessments with this error was 1.48% of assessments completed by the Agency (2305 completed total). In an interview completed with the Administrator on 6/4/25 at 12:30 PM, Surveyor 2 showed Administrator the “Home Health Error Summary” report which indicated that 34 OASIS assessments were late by the agency. The Surveyor asked the Administrator who was responsible for submitting assessments to OASIS. Administrator reported that the QA team meets with her every morning and they all work together to ensure timely submissions. The Surveyor asked what the agency’s process was to ensure timely submissions of assessments. The Administrator stated that they incentivize the providers to submit assessments on time. She stated they generally try to have them submitted within 24 hours, with a hard cutoff of 5 days. She stated they track this very closely to ensure they are submitted on time. Surveyor 2 asked why there was a pattern of late submission. The Administrator stated that a small percentage of assessments were usually rejected due to clerical errors, and when they resubmit, it was then outside of the 30 day window and considered late. Surveyor 2 asked how late assessment submissions impacted client care. The Administrator reported that she did not think it did, because the clients were still receiving all their ordered care, and it was just clerical errors that were causing the submission errors. Review of the Agency’s policy titled “Timelines,” last reviewed 10/25/24, revealed a document that read in part, “All completed and encoded OASIS data will be transmitted…using electronic communication software that complies with the Federal Information Processing Standard from the Agency or the Agency Contractor to the CMS collection site within 30 days of the M0090 date.””

“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 interview and record review, the agency failed to provide federally mandated infection control education in accordance with OSHA§484.60, which requires annual training on Bloodborne Pathogen training for all employees and contractors, in 5 out of 10 personnel records reviewed (OT A, MSW A, PTA Z, PT C, and ST A). Failure of the agency to ensure staff receive annual training on OSHA mandated infection control topics placed the employees at risk for not being aware of the latest information regarding infection control to ensure they are providing care in a way that protects both themselves and the patients from exposure to bloodborne diseases. Findings included: Review of the OSHA 29 CFR Part 1910.1030, titled “Bloodborne Pathogens”, and last updated 5/14/2019 (https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030), revealed regulations that read, in part, “Information and Training: The employer shall train each employee with occupational exposure in accordance with the requirements of this section. Such training must be provided at no cost to the employee and during working hours. The employers shall institute a training program and ensure employee participation in the program. Training shall be provided as follows: At the time of initial assignment to tasks where occupational exposure may take place; At least annually thereafter. Annual training for all employees shall be provided within one year of their previous training.” Review of the agency’s policy titled, “Infection Control Program”, dated 1/1/25, revealed a document that read, in part, “Upon hire and annually thereafter, all Agency employees will be educated regarding the policies and procedures related to: Infection Control Program, Exposure Control Plan, Bloodborne/Airborne/HIV Pathogen Program…” Review of the agency’s policy titled, “Exposure Control”, dated 2/1/25, revealed a document that read, in part, “the Agency will design, implement, and evaluate annually an Exposure Control Plan which will include:…Ensuring that education, exposure follow-up, and documentation will be completed as outlined in the Bloodborne Pathogen Program, per Occupational Safety and Health Administration (OSHA) 29 CFR Part 1910.1030, relating to Bloodborne Pathogens, Airborne Pathogen Program, and Hazardous Materials Program.” Further review of the document revealed the following: “Agency Responsibilities: To provide training and information related to airborne and bloodborne pathogens for all HCP upon hire and annually thereafter. To provide training and information related to HIV/AIDS for all HCP upon hire and annually thereafter…To maintain current and accurate logs and summaries as required by OSHA.”’ Review of personnel record files revealed no documentation of Bloodborne Pathogen training the files. In an interview with the Administrator on 6/3/25 at 3:00 PM, Surveyor 2 noted that the personnel files provided by the agency did not contain documentation of Bloodborne Pathogen training in 10 out of 10 of the files reviewed. The administrator states she provided Bloodborne Pathogen training annually as part of the required Inservice and that was kept in the Inservice binder. She provided the sign-in sheets and education provided to Surveyor 2. Record review of document titled, “Inservice Sheet” dated 1/16/23, with the subject summary of “see attached” revealed the following attendees: Administrator/SN (presenter), Alt. Administrator/Alt. SN, RN A, PT B, RN Z, RN C, RN D, and LVN A. The attached education revealed a copy of the agency’s infection control policy, and an article titled, “Preventing the Spread of Bloodborne Pathogens” and the appropriate education. Record review of document titled, “Inservice Sign In List” dated 8/16/24, with the subject summary of “Infection Control” revealed the following attendees: Administrator/SN (presenter), RN Z, PT B, RN Z, Alt. Administrator/Alt. SN, and RN C. The attached education revealed an article titled, “Preventing the Spread of Bloodborne Pathogens” and the appropriate education. Record review of document titled, “Inservice Sign In List” dated 2/21/25, with the subject summary of “see attached” revealed the following attendees: Administrator/SN (presenter), RN C, RN A, LVN X, Marketer B, PT A, RN E, Alt. Administrator/Alt. SN, LVN A, RN Z, CAN A, and Marketer C. The attached education revealed a copy of the agency’s infection control policy, and an article titled, “Preventing the Spread of Bloodborne Pathogens” and the appropriate education. Based on these records, of the 10 personnel files reviewed, 5 employees/contractors (OT A, MSW A, PTA Z, PT C, and ST A) have not had bloodborne pathogen training in the last year. During an interview with the Administrator on 6/4/25 at 10:40 AM, Surveyor 2 stated she could not locate documentation of annual bloodborne pathogen training on OT A, MSW A, PTA Z, PT C, and ST A. The administrator stated those were mainly contracted employees. Surveyor 2 shared the regulation that stated the annual training applied to contractors as well as employees. Surveyor 2 asked how the Administrator ensures her contracted employees are completing the required training. She stated that a lot of them work for other agencies as well, and if they work more hours there, she instructs them that their CEUs and Inservice can be done with that agency. Surveyor asked if she had documentation of this and administrator was unable to provide. During an interview with the Administrator on 6/4/25 at 12:30 PM, Surveyor 2 asked who was responsible for ensuring at all employees, including contractors, completed their annually required training. She said it was her responsibility. Surveyor 2 asked if she did not require contracts to provide documentation of their bloodborne pathogen training to her, how did she ensure that it was completed? She stated, “I know it was done because they tell me they have completed their CEUs for their license verification.” Surveyor explained that license verification can include a wide range of CEUs and was typically biannual, so renewing a license does not necessarily mean that Bloodborne Pathogen training has been completed annually. Surveyor 2 asked how not ensuring all employees/contractors receive annual training on Bloodborne Pathogens could affect patient care. The Administrator stated that it may affect client care. She stated all employees and contractors were educated on standard precautions, but if they really have not had recent training bloodborne pathogen exposure, then possibly they could put patients at a higher risk, but she emphasized there has been no trend in their patient’s exposure to Bloodborne Pathogens.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide proper written notice in advance of terminating on-going care for 3 of 3 discharged patients (Patient 8, Patient 9, and Patient 10). Failure of the agency to provide proper written notice in advance of terminating care resulted in clients being uninformed on how to request an expedited determination from their beneficiary and family centered care quality improvement organization. Findings included: Record review of clinical record for Patient 8 revealed a document titled “Discharge Order,” signed and dated 02/12/2025 that read “DC from HH services effective 2/12/25 [sic] due to goals met.” This discharge date of 02/12/2025 was verified as a visit in Client 8’s clinical record Record review of clinical record for Patient 8 revealed a document titled “Agency Name Home Health Agency 5 Day Discharge Notice,” dated 02/06/2025. The form indicated that Patient 8 was notified by phone and was missing a signature by Patient 8. This form is not the NOMNC or DENC required by CMS. Record review of clinical record for Patient 9 revealed a document titled “Discharge Order,” dated 05/17/2025 that read “the patient was discharged from home health services effective 05/17/2025, following the completion of the OT treatment plan.” This discharge date of 05/17/2025 was verified as a visit in Patient 9’s clinical record. Record review of clinical record for Patient 9 revealed a document titled “[Agency Name] Home Health Agency 5 Day Discharge Notice,” dated 05/10/2025. This form was not the NOMNC or DENC required by CMS. Record review of clinical record for Patient 10 revealed a document titled “Discharge Order,” signed and dated 05/13/2025 that read “the patient is [sic] to be discharged from home health services effective 05/05/2025” This discharge dated of 05/05/2025 was verified as a visit in Patient 10’s clinical record. Record review of clinical record for Patient 10 revealed a document titled “[Agency Name] Home Health Agency 5 Day Discharge Notice,” dated 05/05/2025. This form was not the NOMNC or DENC required by CMS. Review of policy titled “Patient/Client Transfer and Discharge Notices,” dated 02/01/25, revealed the following: “Agency staff will deliver a completed and valid NOMNC to the patient/client, or representative (if any): 1. when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. 2. At least two (2) calendar days before Medicare covered services end or the second to last day os service if care is not provided daily.” Review of CMS webpage titled “Notices and Forms,” last updated 11/18/2024 (https://www.cms.gov/medicare/appeals-grievances/managed-care/notices-forms), revealed under the subsection titled “Notice of Termination of Services (SNF, HHA, CORF)” that “a provider must issue advance written notice to enrollees before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF).” The subsection further indicated that “the two notices used for this purpose are: Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123-NOMNC, and the Detailed Explanation of Non-Coverage (DENC) Form CMS-10124-DENC.” Review of CMS webpage titled “FFS & MA NOMNC/DENC,” last updated 05/13/2025 (https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-ma-nomnc-denc), read in part “HHAs, SNFs, Hospices, and CORFs are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending.” In an interview with the Administrator and AA on 6/4/2025 at 11:10 AM, Surveyor 1 asked if a NOMNC or DENC was provided to Patients 8, 9, and 10 prior to discharge. The Administrator responded that she did not know what a NOMNC or DENC was. Surveyor 1 responded that they were the forms required by CMS to be provided to licensed and certified home health patients. Surveyor 1 confirmed with the Administrator that Patient 8, Patient 9, and Patient 10 were licensed and certified home health patients. Surveyor 1 showed the Administrator and AA the HHA’s discharge policy, which indicated that they used NOMNCs. The Administrator and AA responded that they had never used NOMNCs and that they were unaware that they had to use them. Surveyor 1 asked if not using the proper forms impacted client care. The Administrator responded no, that it has never seemed to interfere with client care and that they use a different form to provide discharge notice. In an interview with the Administrator and AA on 6/4/2025 at 11:35 AM, Surveyor 1 showed the Administrator and AA that the discharge notice for Patient 8 indicated that it occurred by phone and that the phone call took place on 2/6/25. The Administrator and AA verified that that was correct. Surveyor 1 showed the final visit document titled “Discharge Summary,” dated 02/12/2025 and asked if that was the same document RN Y referenced when she wrote “see DC OASIS visit” in the space for the signature on the discharge notification. The Administrator and AA confirmed that was the correct document. Surveyor 1 noted that there was not a patient signature on that visit note. The Administrator and AA reviewed and visit note and confirmed that it did not include a patient signature. The Administrator reported that RN Y called Patient 8 on 2/6/25 to discuss discharge, but a written copy of the discharge notification was not provided to the client on or 5 days prior to discharge. At this time, the Administrator also reported that she had called RN Z, and that RN Z informed her that though she had spoken with the family of Patient 10 in the weeks before about discharging, she did not provide a written notice of discharge to Patient 10 until the day of discharge. On 6/4/25 at 12:08 PM, Surveyor 1 attempted to call RN Z for an interview. RN Z did not answer, and Surveyor 1 left a voicemail requesting a callback. RN Z did not return phone call. On 6/4/25 at 12:09 PM, Surveyor 1 attempted to call RN Y for an interview. RN Y did not answer, and Surveyor 1 left a voicemail requesting a callback. RN Y did not return phone call.”

“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 observation, record review, and interview, the agency failed to maintain a current medication list for 2 of 4 patients for which home visits occurred (Patient 1 and Patient 2). This failure placed patients at risk of undetectable adverse events due to medications. Findings included: Record review of document titled “Medication Profile,” dated for the certification period of 4/15/2025-6/13/2025, revealed that the current list of medications for Patient 2 included the following: Buspirone HCl 5 mg, hydroxyzine HCl 25 mg, Topiramate 25 mg, Protonix 40 mg, Jardiance 10 mg, Flovent Diskus Inhalation 100 mcg/blist, Breo Ellipta inhalation 100-25 mcg/inh, Spiriva Respimat 1.25 mcg/act, oxygen 2 liters, Nexium 40 mg, Odansetron HCl 4 mg, metformin HCl 500 mg, triamcinolone acetonide 0.1%, Hydrocodone-Acetaminophen 10-325 mg, Flunisolide 25 mcg/act, Cortizone-10 Eczema 1%, Torsemide 20 mg, Esomeprazole Magnesium 20 mg, Ipraptropium Bromide 0.02%, Nitrostat Sublingual 0.4 mg, Vitamin C 500 mg, Acidophillis, Lisinopril 2.5 mg, Vitamin D3 125 mcg (5000 UT), Aspirin 81 mg, Probiotic, Levothyroxine Sodium 50 mcg, Sertraline HCl 50 mg, Simvastatin 20 mg. The medication list did not include Dicyclomine 10 mg or a prenatal vitamin despite those medications being observed amongst Patient 2’s medications and Patient 2’s caregiver providing confirmation that they were active medications. The medication list included Vitamin D3 125 mcg (5000 UT), the Probiotic, metformin HCl 500 mg, Nexium 40 mg, and hydroxyzine HCl 25 mg, but they were not present amongst Patient 2’s medications and Patient 2’s caregiver confirmed they were not active medications. Record review of document titled “Medication Profile,” dated for the certification period of 4/20/2025-6/18/2025, revealed that the current list of medications for Patient 1 included the following: Carvedilol 25 mg, oxybutynin chloride ER 10 mg, Lantus 100 unit/mL, Jardiance 10 mg, Dicyclomine HCl 20 mg, Topamax 25 mg, Methocarbamol 500 mg, Sertraline HCl 100 mg, Nystop External 10000 unit/gm, Clotrimazole-Betamethasone External 1-0.05%, Fluticasone Proprionate (Inhal) Inhalation 50 mcg/blist, Combivent Respimat Inhalation 20-100 mcg/act, Budesonide inhalation 0.5 mg/2ml, Advair HFA Inhalation 230-21 mcg/act, Vitamin D2 125 mcg (5000 UT), Hydrocodone-Acetaminophen 10-325 mg, Colace 100 mg, trazodone HCl 50 mg, Cymbalta 30 mg, Vitamin C 500 mg, Cranberry Concentrate 500 mg, Lomotil 2.5-0.025 mg, Gabapentin 100 mg, Zofran 4 mg. Allergy Relief Nasal 50 mcg/act, Rosuvastatin Calcium 10 mg, Alprazolam 0.25 mg, Triamcinolone Acetonide 0.5%, Clopidogrel Bisulfite 75 mg, Pantoprazole Sodium 40 mg, ipratropium-albuterol 0.5-3mg/3 ml, Humalog 100 unit/ml. The medication list did not include Diphenoxylate-atrop 2.5-0.025, Topamax 50 mg, or sertraline HCl 25 mg, despite those medications being observed amongst Patient 1’s medications and Patient 1 providing confirmation that they were active medications. The medication list included Topamax 25 mg and sertraline HCl 100 mg, but they were not present amongst Patient 1’s medications and Patient 1 confirmed they were not active medications. During a home visit on 6/3/2025 at 10:00 AM, Surveyor 1 requested to see Patient 2’s medications and compared them to the medication list obtained from the HHA’s electronic medical record the day prior. Surveyor 1 observed a medication bottle with a label titled “Dicyclomine 10 mg” with a fill dated of 3/6/2025. Patient 2’s caregiver reported that Patient 2 took this medication and that she has been for a while but could not remember the exact start date, likely around the time of 3/6/2025 when it was filled. Surveyor 1 observed a bottle titled “Prenatal Multivitamin” and Patient 2’s caregiver reported she took this medication once a day. Surveyor 1 reported to LVN X that these two medications were not present on the medication list and LVN X verified that they were not on her list either and that the agency must have missed it. Surveyor 1 requested to see the medications that were listed on the med list, but not present in Patient 2’s medication bags: hydroxyzine, Nexium, metformin, esomeprazole, Vitamin D3, and a second probiotic. Patient 2’s caregiver reported that Patient 2 has not taken any of those medications in a very long time, but she could not remember the exact date that she stopped taking them. During a home visit on 6/3/2025 at 10:35 AM, Surveyor 1 requested to see Patient 1’s medications and compared them to the medication list obtained from the HHA’s electronic medical record the day prior. Surveyor 1 observed a medication bottle with a label titled “Diphenoxylate-atrop 2.5-0.25” with a fill date of 3/5/2025. Patient 1 reported that she has taken that medication since around the fill date for as needed diarrhea. Surveyor 1 observed a medication bottle for Topamax 50 mg. Surveyor noted to LVN X that the dose listed in the HHA electronic medical record was 25 mg. Patient 1 stated that she did not remember when the dose changed from 25 mg, but that she has been taking 50 mg for a while. Surveyor 1 observed a medication bottle for sertraline 25 mg and reported to LVN X that the dose listed on the HHA electronic medical record was 100 mg. Patient 1 stated that she has been taking 25 mg of sertraline since 04/28/2025 after he provider decreased the dose. Surveyor 1 asked if Patient 1 was still used an inhaler called “Budesonide” as it was not provided with her other medications but was listed on the HHA electronic medical record. Patient 1 stated that she did not think so and that all of her inhalers were on the counter so if that was not present then she did not use it. Review of policy titled “Medication List and Monitoring,” dated 05/02/24, revealed that “the agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient/client. […] Professional clinical staff will update the medication list with any changes in the medication regimen.” In an interview with LVN X on 6/3/25 at 11:58 AM, Surveyor 1 asked what LVN X’s process was for completing medication reconciliation with Patients 1 and 2. LVN X stated that she asks the clients about any changes to their medications at each visit and she relies on patients and caregivers to report any changes. Surveyor 1 asked how often LVN X compared the physical medications that patients reported taking to the HHA electronic medical record. LVN X reported that she does not do this, but that it should occur every 60 days by a RN during the recertification visit. Surveyor 1 asked LVN X why she thought the medication lists for Patient 1 and Patient 2 did not accurately reflect the medications that they were taking. LVN X reported that she thought it was because sometimes patients forget to report when they are taking a new medication or when they stop taking one. In an interview on 6/4/25 at 12:45 PM with the Administrator, Surveyor 1 reported the inconsistencies between the medications that Patient 1 and Patient 2 had in the home and reported to be currently taking, compared to their current medication lists obtained from the HHA’s electronic medical records. Surveyor 1 described how both clients had medications that they were taking that were not listed on their medication lists and how their medications lists contained medications that they were not taking. Surveyor 1 asked about the process for ensuring accurate medication lists for clients and how often nurses should be looking at patients’ physical medications. The Administrator replied that nurses should be reviewing the patients’ physical medications at every visit and comparing them to what is documented in the electronic medical record. Surveyor 1 asked how this impacted patient care. The Administrator reported that not maintaining an accurate medication list could interfere with care coordination when patients have multiple providers.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to include all skilled professionals in their QAPI meetings in 3 out of 6 QAPI meetings (2/23/22, 4/28/23, 4/19/24) in the 3 years reviewed (2022, 2023, 2024). Failure of the agency to have all disciplines of skilled professionals represented in the QAPI program resulted in missed opportunity for the Occupational Therapists to provide clinical input on best practices and contribute to improving patient care. Findings included: Review of document titled “Inservice Sign- In Sheet,” dated 12/23/22, with the subtitle, “Name of Inservice: Q2 2022 QAPI Meeting,” revealed a document with names and signatures of meeting attendees. The list included the following: Administrator/SN, Alt. Administrator/Alt. SN, QA Manager A, QA Manager B, QA Member C, Operations Manager, MSW A, ST A, PT A, CEO, Medical Director A, Office Manager, Marketer A, and Medical Director B. According to this record, no OT attended the 12/23/22 QAPI meeting. Review of document titled “Inservice Sign- In Sheet,” dated 4/28/23, with the subtitle, “Name of Inservice: 2023 QAPI Meeting revealed a document with names and signatures of meeting attendees. The list included the following: Administrator/SN, Alt. Administrator/Alt. SN, QA Manager A, QA Manager B, QA Member C, Operations Manager, MSW A, ST A, PT A, CEO, Medical Director A, Office Manager, Marketer A, and Medical Director B. According to this record, no OT attended the 4/28/23 QAPI meeting. Review of document titled “In-service Sign- In Sheet,” dated 4/19/24, with the subtitle, “Name of Inservice: Q1 2024 QAPI Meeting,” revealed a document with names of signatures of meeting attendees. The list included the following: Administrator/SN, Alt. Administrator/Alt. SN, QA Manager A, QA Manager B, QA Member B, Operations Manager, MSW A, ST A, PT A, CEO, Medical Director A, Office Manager, Marketer A, and Medical Director B. According to this record, no OT attended the 4/19/24 QAPI meeting. In a phone interview with OT A at 10:00 AM on 6/9/25, he stated he was an independent contractor at [Agency Name]. Surveyor asked if he was involved in the QAPI committee at Progressive. OT A stated that he was not specifically involved in QAPI but that he called into the office to report on his patients. He stated he usually just had a few patients. Surveyor asked when he called the office, was it during the QAPI meetings or just periodically? He stated he called periodically and as needed to provide updates on his patients. Surveyor shared that his name was on 3 out of 6 of the QAPI meeting attendance sheets, but that the Office Manager stated that he was in attendance at all QAPI meetings. Surveyor asked if he recalled calling in for or attending these meetings in person. OT A stated that he did remember occasionally calling in for these meetings, but they were so few and far between, and that he did not remember specifically which meetings he did or did not attend/call-in for. In an interview with the Administrator on 6/4/25 at12:30 PM, Surveyor 2 verified the attendance of the QAPI meetings for 2022, 2023, and 2024 with the Administrator. The Surveyor also confirmed with the Administrator that OT services were being offered to patients during the time the QAPI meetings occurred. The Surveyor asked who was responsible for setting up QAPI meetings and deciding who attended. The administrator stated that was primarily her responsibility. Surveyor 2 confirmed with the Administrator that the services provided by the agency included SN, MSW, PT, OT, and ST. Surveyor 2 asked why an OT was not included in 3 out of 6 of the QAPI meetings since they offer those services to patients. The Administrator stated she was not sure why OT A’s name was not documented. She stated he may have attended via Zoom, but she had no record of this and could not say for certain. She stated he was often busy with patients and was less available to attend meetings. Surveyor 2 asked the Administrator if they thought not having all skilled professionals participate in QAPI impacted patient care. Administrator reported that since an OT was present at some of the meetings throughout the year, she did not think it significantly impacted patient care. She stated she understood the importance of everyone on the team giving input, but that the other therapists were present and capable of addressing OT functions. The Surveyor asked how the other therapists would communicate important items discussed at the QAPI meetings with the OT since they were independent contractors and not in any supervisory capacity over each other. The administrator stated all their employees and contractors communicate. Record review of the agency policy titled, “Administrative Policy Manual – Quality Assessment and Performance Improvement Program,” last reviewed 5/1/24, revealed a document that read, in part, “The QAPI Committee will consist of, at a minimum, the Administrator, Supervising Nurse or therapist, and individuals representing the scope of services provided by the Agency. The QAPI Committee will meet twice a year or more often if needed and will maintain a written record of the meetings with appropriate signatures.””