The Medical Team 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 record review and interview, the agency failed to include skilled professionals in their QAPI meetings in 6 out of 6 QAPI meetings over the last 3 years. Failure of the agency to have skilled professionals represented in the QAPI program resulted in missed opportunity for the employed Registered Nurses to provide clinical input on best practices and contribute to improving client care. Findings included: Review of document titled “Quarterly Performance Improvement Meeting,” dated 04/18/2022, revealed that attendees included the Administrator and the PAS Coordinator/Supervisor. An attendant did not attend this meeting. Review of document titled “Organization Budget and Activities,” dated 04/25/2022, revealed that attendees included the Chief Financial Officer, Chief Executive officer, Director of Clinical Operations, Vice President, and previous administrator. A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 04/20/2023, revealed that attendees included the Administrator and the PAS Coordinator/Supervisor. A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 10/13/2023, revealed that attendees included the Administrator, Attendant A, and the PAS Coordinator/Supervisor . A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 04/08/2024, revealed that attendees included the Administrator and the PAS Coordinator/Supervisor. A nurse did not attend this meeting. Review of document titled “Quarterly Performance Improvement Meeting,” dated 10/07/2024, revealed that attendees included the Administrator, Attendant A, and the PAS Coordinator/Supervisor . A nurse did not attend this meeting In an interview with the administrator at 2:25 PM on 3/17/25, the administrator asked Surveyor B if the Supervising Nurse had to be in-person at the QAPI meetings. Surveyor B asked the administrator if the Supervising Nurse had called in by phone for the meetings. Administrator did not answer the question but stated he “discussed everything” with the Supervising Nurse. Supervising Nurse/s name was not on the attendance list at this time. In an interview with the administrator and PAS Coordinator on 3/20/25 at 1:52 PM., Surveyor went through all documented QAPI meetings for the last 3 years and had administrator and coordinator confirm the signatures on attendance sheets. Administrator and Coordinator reported that the people who attended the meetings held the positions listed above. Surveyor showed Administrator and PAS Coordinator the agency’s QAPI policy indicating requirements for meetings. Administrator reported that the coordinator also performs the role as supervisor for attendants. Surveyor A asked why the attendant did not attend the QAPI meetings. Administrator stated she is often busy taking care of patients and unable to come to the agency for the meetings. Surveyor A asked why the Supervising Nurse did not attend the meetings. Administrator stated the Supervising Nurse lives in a different city, but that he is updated on the content of the meetings. He stated he did not think the Supervising Nurse needed to be there because they are not currently providing skilled nursing services to any patients. Surveyor B asked how not including all necessary parties at the QAPI meetings could impact client care. Administrator reported that he did not think it impacted client care because they talk to the team every day. In a record review of agency policy titled, “Quality Assessment Performance Improvement Plan”, undated, the document read, “The QAPI Committee will consist of, at a minimum, the Administrator, Supervisor, representation from disciplines providing services.””