Caprock Home Health Services Inc.

“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 interview and record review, the agency failed to include all skilled professional staff in its quality assessment and performance improvement program for 3 of 3 years (2022, 2023, and 2024). This failure placed patients at risk of receiving suboptimal care. Findings included: Review of document titled “(Agency) Home Health Care Quality assessment and Performance Improvement Meeting,” dated 4/29/2022 and 5/13/2022 revealed that the following members were in attendance: Former Administrator, Former SN 1, PT, RN Case Manager, PAS Director, CLASS Director, HH Aide, and Communications Officer. No representatives for ST or OT were recorded as present at the meeting. Review of document titled “CHHS QAPI Meeting Sign-in Sheet” dated 4/29/22 revealed that the following members were in attendance: Former Administrator, Former SN 1, RN Case Manager 1, PAS Director, CLASS Director, HH Aide, PT, and Communications Officer. No representative for ST or OT was recorded as present at the meeting. Review of document titled “CHHS QAPI Meeting Sign-in Sheet” dated 5/13/22 revealed that the following members were in attendance: Former Administrator, Former SN 1, RN Case Manager 1, PAS Director, CLASS Director, HH Aide, PT, and Communications Officer. No representative for ST or OT was recorded as present at the meeting. Review of document titled ““(Agency) Home Health Care Quality assessment and Performance Improvement Meeting,” dated 10/27/22 revealed that the following members were in attendance: Former Administrator, Former SN 2, PT, OT, RN Case Manager 1, PAS Director, CLASS Director, HH Aide, and Communications Officer. No representative for ST was recorded as present at the meeting. Review of document titled “CHHS QAPI Meeting Sign-in Sheet” dated 10/27/22 revealed that the following members were in attendance: Former Administrator, Former SN 2, RN Case Manager 1, PAS Director, CLASS Director, HH Aide, PT, OT and Communications Officer. No representative for ST was recorded as present at the meeting. Review of document titled “(Agency) Home Health Care Quality assessment and Performance Improvement Meeting,” dated 4/24/23 revealed that the following members were in attendance: Former Administrator, Former SN 2, PT, RN Case Manager 2, Former AA, CLASS Director, and HH Aide. No representative for ST, OT, or PAS were recorded as present at the meeting. Review of document titled “CHHS QAPI Meeting Sign-in Sheet” dated 4/24/23 revealed that the following members were in attendance: Former Administrator, Former SN 2, PT, OT, Communications Officer, PAS Director, RN Case Manager 1, RN Case Manager 2, Former AA, CLASS Director, and HH Aide. No representative for ST was recorded as present at the meeting. Review of document titled “(Agency) Home Health Care Quality assessment and Performance Improvement Meeting,” dated 10/18/23 revealed that the following members were in attendance: Former Administrator, Former SN 2, PT, CLASS Director, Communications Officer, PAS Director, OT, and HH Aide. No representative for ST was recorded as present at the meeting. Review of document titled “CHHS QAPI Meeting Sign-in Sheet” dated 10/18/23 revealed that the following members were in attendance: Former Administrator, Former SN 2, PT, CLASS Director, RN Case Manager 2, Communications Officer, PAS Director, OT, and HH Aide. No representative for ST was recorded as present at the meeting. Review of document titled “(Agency) Home Health Care Quality assessment and Performance Improvement Meeting,” dated 4/25/24 revealed that the following members were in attendance: Former Administrator, Former SN 2, PT, RN Case Manager 3, PAS Director, CLASS Director, and Communications Officer. No representatives for ST or OT were recorded as present at the meeting. Review of document titled “CHHS QAPI Meeting Sign-in Sheet” dated 4/25/24 revealed that the following members were in attendance: Former Administrator, Former SN 2, PT, Communications Officer, PAS Director, RN Case Manager 3, and CLASS Director. No representatives for ST, OT or home health aides were recorded as present at the meeting. Review of document titled “(Agency) Home Health Care Quality assessment and Performance Improvement Meeting,” dated 10/10/24 revealed that the following members were in attendance: Former Administrator, Former SN 3, CLASS Director, and Communications Officer. No representatives for ST, PT, OT, PAS, or home health aides were recorded as present at the meeting. This meeting did not have a corresponding sign-in sheet. Review of document titled “Position Description: Administrator,” for Former Administrator, signed and dated 2/22/2018, revealed that the role of administrator included “direction and supervision of the Quality Assurance and Performance Improvement (QAPI) activities for the provider office, with meetings no less than semi-annually, including the entire scope of operations.” In an interview with the Administrator on 7/8/25 at 11:30 AM, the surveyor asked the Administrator to verify the scope of services provided by the agency. The Administrator reported that the scope of services provided by the HHA included skilled nursing, physical therapy, occupational therapy, home health aides, personal attendant services, and speech therapy. The surveyor asked if those have always been the scope of services provided by the agency. The Administrator stated that they always had those services. In an interview with Former Administrator and Administrator on 7/8/25 at 3:15 PM, the surveyor showed Former Administrator that QAPI attendance logs from 2022, 2023, and 2024 did not include ST, OT, PT, home health aides, and/or a PAS representative at various meetings. Former Administrator verified meeting attendance as recorded for the following meeting dates: 4/29/22, 5/13/22, 10/27/22, 4/24/23, 10/18/23, 4/25/24, and 10/10/24. Surveyor asked why all scope of services were not represented at QAPI meetings. Former Administrator stated that ST and OT were contracted services and so apart from sending an invitation and offering to provide a free lunch, those contractors were not incentivized to come, or they had other conflicts at the time of the meetings. For meetings where the PT, home health aide, or PAS was not represented, those employees must have been out on leave or had a conflict. The surveyor asked if not having all services represented at QAPI meetings impacted patient care. Former Administrator stated that it did not, and that they have a messaging forum where everyone was constantly in communication, so if any issues or areas that needed improvement came up, then those members could communicate them. Surveyor asked whose responsibility it was for ensuring that the QAPI program and meetings included the scope of services provided by the agency. Former Administrator stated that it was the role of the Administrator to ensure that meeting attendance included the full scope of services. Surveyor asked Administrator if they had anything to add. Administrator responded no. Review of policy titled “Quality Assurance and Performance Improvement (QAPI), “ dated 3/2022, revealed that 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, [and] 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.” Review of policy titled “Scope of Services,” dated 2/2018, revealed that areas of services provided by the agency included nursing care, physical therapy, occupational therapy, speech therapy, home health aide services, social work services, and bundled medical supplies.”