Careworks Home Health Services 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 record review and interview, the agency failed to have at least one performance improvement project (PIP) either in development, on-going, or completed each calendar year for 3 (2022, 2023, 2024) of 3 years reviewed. This failure could result in patient’s receiving inadequate care or complaints and service failures not being identified and addressed to improve quality of care. Findings: Record review of the undated QAPI documentation provided to the surveyor by the agency revealed a lack of PIP documentation for 2022, 2023, and 2024. In an interview 7/29/2025 at 1:30pm, the surveyor asked Administrator (ADM) and Alternate Administrator (AADM) who was responsible for the QAPI program. AADM stated, “Director of Nurses (DON) is.” Surveyor informed ADM and AADM that unable to locate a PIP for 2022, 2023, or 2024. ADM and AADM looked in the area where the QAPI documentation had been located. Both ADM and AADM stated, “we don’t have one [PIP].” On 7/29/2025 at 2:30pm, the surveyor spoke with DON, ADM, and AADM. The surveyor asked DON who was responsible for the QAPI program and documentation. DON stated, “I am.” Surveyor asked DON to show them the PIPs for 2022, 2023, and 2024. DON stated, “I didn’t know we had to do one. The consultants and other surveyors never said anything about it.” When asked how not having PIPs could affect patient care DON C stated, “there could be an problem with the quality of care.” The agency had a policy (QAPI.5) dated 5/1/24 titled; “Quality Assessment Performance Improvement Program.” The policy read in parts: “…Procedure: …III. …E. Performance improvement projects: 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons conducting these projects, and the measurable progress achieved on these projects…” The agency had a policy (QAPI.25) dated 5/1/24 titled; “Performance Improvement Process: Improvement Activities.” The policy read in parts: “…Purpose: To establish a standard for achieving and sustaining improved performance. Policy: …II. The governing body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually. …IV. All performance improvement activities/ projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved…””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to include a description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors in the plan of care for 6 (Patient #1, #2, #3, #4, #5, #6) of 6 active patient records reviewed. This failure could result in a lack of interventions causing the patient unnecessary emergency room or hospital visits. Findings: Record review of Patient 1’s medical record revealed the patient was admitted to services on 9/23/2024. Review of the plan of care for benefit period 5/21/25-7/19/25 revealed the description of the patient’s risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors was not located in the plan of care. Record review of Patient 2’s medical record revealed the patient was admitted to services on 4/5/2025. Review of the plan of care for benefit period 4/5/25-6/3/25 revealed the description of the patient’s risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors was not located in the plan of care. Record review of Patient 3’s medical record revealed the patient was admitted to services on 4/28/2023. Review of the plan of care for benefit period 4/17/25-6/15/25 revealed the description of the patient’s risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors was not located in the plan of care. Record review of Patient 4’s medical record revealed the patient was admitted to services on 5/22/2024. Review of the plan of care for benefit period 5/17/25-7/15/25 revealed the description of the patient’s risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors was not located in the plan of care. Record review of Patient 5’s medical record revealed the patient was admitted to services on 10/2/2024. Review of the plan of care for benefit period 5/30/25-7/28/25 revealed the description of the patient’s risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors was not located in the plan of care. Record review of Patient 6’s medical record revealed the patient was admitted to services on 3/8/2023. Review of the plan of care for benefit period 4/26/25-6/24/25 revealed the description of the patient’s risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors was not located in the plan of care. During an interview with the Administrator (ADM) and Alternate Administrator (AADM) on 7/29/2025 at 1:30pm, the surveyor asked why the plan of care was missing the risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors. The Administrator stated, “I don’t know why it isn’t on there [POC]. On 7/29/2025 at 2:30pm the surveyor met with the Director of Nurses (DON), Administrator (ADM), and Alternate Administrator (AADM). The surveyor asked about the plan of care missing the risk for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors for 6 patients. The DON stated, “it is on the Outcome and Assessment Information Set (OASIS). I didn’t realize it wasn’t getting to the plan of care.” ADM stated, “it’s an issue with the electronic medical record. I have already put in a request to address the issue.” When asked how the risks for emergency department visits and hospital readmission and all necessary interventions to address the underlying risk factors not being on the plan of care affected or could affect the patient, DON stated, “they might go to the hospital.” The agency had a policy (PC.35) dated 5/2/24 titled; “Plan of Care.” The policy read in parts: “…Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/ client’s specific needs and problems… …Procedure: …III …A. The individualized plan of care must include the following: …12. A description of the patient’s/ client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors…””