Homecare Solutions of East Texas 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 in its quality assessment and performance improvement (QAPI) committee the required staff in 2023, 2024, and 2025. The agency did not ensure a member of each scope of service attended all QAPI meetings in 2023, 2024, and 2025. This failure could prevent the agency from identifying problems in the service categories that were not represented and therefore could place the patients at risk of receiving substandard care and services. Findings included: Record review of QAPI meeting minutes for July 2023-December 2023 dated 1/18/2026 included the committee members did not indicate a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for January – March of 2024 dated 4/18/2024 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for April-June of 2024 dated 7/19/24 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for July-September of 2024 dated 10/18/2024 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for October-December of 2024 dated 1/17/2025 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for January-March of 2025 dated 4/18/2025 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for April-June of 2025 dated 7/18/2025 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for July-September of 2025 dated 10/18/2025 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of QAPI meeting minutes for October-December of 2025 dated 1/06/2026 indicated the committee members did not include a Physical Therapist or Occupational Therapist was present for the meeting. Record review of a document titled Duplicated Patient and Visit Counts by discipline dated 8/25/2023-8/25/2026 indicated Physical therapy made 1, 149 visits and Occupational therapy made 37 visits. During an interview on 8/24/2026 at 2:31 p.m., the Alternate Administrator said all of the agencies therapist were contracted and none of them participated in QAPI. The Alternate Administrator said their Patients had always received therapy services as ordered and if the therapist had any questions about what was going on with a patient they could call the agency and have a meeting with administrative staff. During an interview on 8/26/2026 at 11:00 a.m., the DON said she attended QAPI meetings which are held several times per year. She said the Alternate Administrator was responsible for QAPI. She said herself, the Alternate Administrator, the Alternate DON, and the Administrator were all members of the QAPI committee. The DON said she had never seen a therapist (PT or OT) attend the QAPI meetings. The DON said proper QAPI committee members were important to ensure if there were any issues going on with the agency or the Patients, those issues could be addressed and fixed or improved. During an interview on 8/26/2026 at 11:20 a.m., The Alternate Administrator said she was responsible for QAPI. She said the QAPI committee members included herself, the DON, the Alternate DON, and one LVN field nurse. She said QAPI was held quarterly. The Alternate Administrator said she was not aware the contracted therapists had to be part of the QAPI committee or the meetings. She said the Alternate Administrator said QAPI meetings and its committee members were important to discuss all patients as a whole and to ensure the agency was following through with patient care and prevent any issues from arising. During an interview on 8/26/2026 at 11:45 a.m., the Administrator said he took part in the agencies QAPI meetings but was unsure what the policy was for how often the meetings were held. The Administrator said the QAPI committee members included the DON, Alternate DON, the Alternate Administrator and the office supervisor. The administrator said it was his understanding the agency had not included therapy staff in the QAPI meetings because they thought it was not required. The Administrator said the Alternate Administrator handled QAPI. The Administrator said QAPI meetings and members were important because it was required by regulatory and because it kept everyone aligned, identified any issues or problems and allowed the agency to fix any problems or concerns with patients or patient care. Record review of a policy titled Quality Assessment Performance Improvement Plan dated 10/01/10 indicated the QAPI committee would consist of, at a minimum, the Administrator, supervising nurse, therapist, and individuals representing the scope of services provided by the agency.”