Guardian Angels Plus Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure that a patient received home health services as ordered in the individualized POC for 1 (Patient #1) of 3 discharged patient records reviewed. The RN failed to ensure a Physical Therapy evaluation and treatment plan was completed as ordered by the physician. This failure potentially placed patients at risk of not receiving interventions when needed to prevent complications, and a decline in the patients’ health status. FINDINGS INCLUDE: Review of a Complaint Intake #1074212 dated 03/13/2026 revealed a complainant reported to CII the agency failed to provide patient services. In a phone interview on 07/22/2026 at 8:55 AM with the complainant, the surveyor asked about the care and services for the agency provided for Patient #1 prior to discharge. The complainant stated the (agency) staff came to visit Patient #1 a few times and had promised to send therapy and other staff. The complainant stated no one else came and they were not happy with the way things were going. Patient #1 discharged from the agency to be admitted to another agency for services. Patient #1: Review of the record revealed a POC dated 02/23/2026 to 04/23/2026 with a SOC date 02/23/2026. The POC included the following diagnoses: Fracture (partial or complete break in the bone) of left pubis (the lower and front part of the hip bone); fracture of sacrum (located at the base of the spine at the lower back, wedged between the two hip bones of the pelvis); History of falling; Spinal stenosis (the narrowing of the open spaces in the spine, which can press on the spinal cord and nerves) and Difficulty in walking. The POC listed physician orders for SN visits once a week for nine weeks and PT evaluation and treatment. The POC included, “PT visits are required to establish HEP with focus on exercises to improve balance, gait for safe ambulation, mobility, and transfers. Goal: Patient will have improve in balance/gait/transfer. … Physical therapy eval (evaluation) and treat (treatment) to evaluate week of 02/23/2026. …SN to assess patient’s compliance with home exercise program. …” The POC was digitally signed by RN A and dated 02/23/2026. Review of the record revealed a SOC visit dated 02/23/2026 conducted by RN A. SN missed visits were dated 03/09/2026 and 03/19/2026. A PT referral dated 02/24/2026 included, “Decline Reason: Declining PT service due to no coverage. …” A PT referral dated 02/26/2026 included, “Decline Reason: no coverage. …” No additional PT referrals were requested for a PT evaluation/treatment for Patient #1. A Discharge visit was conducted 03/19/2026 by RN A and included, “… Care Coordination Discharge from home health service … Reason for Discharge: … Per patient / family request, … Another HH … .” In an interview with the DON via teleconference and the Administrator in person, on 07/23/2026 at 3:00 PM, the Surveyor asked if RN A was available. The Administrator stated RN A was not available, but the DON was available via teleconference and would join the conversation. The Surveyor reviewed the findings and asked why RN A did not follow the plan of care and ensure a PT evaluation and treatment plan for Patient #1. The DON stated she (DON) was hired by the agency in April 2026, after the discharge of Patient #1. The Administrator stated the agency had a change in administration during 2025 to 2026 and the agency was re-organizing from changes with therapy companies at the time. He stated the agency only had two contracted PT companies to work with at that time and both had been sent the referral but declined the (patient’s) case. He stated he wasn’t sure if RN A had followed up with the PT referral. The DON stated she has tried to add more therapy companies and signed the agency up with the PT company, Identifier C. Agency policy, revised date 01/01/2026, quoted in part, “Plan of Care, … 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: … II. An RN is responsible for coordinating the Plan of Care when multiple disciplines are involved, or when more than one agency is involved, … V. Each patient/client must receive the home health services that are written in an individualized Plan of Care, …” Agency policy, revised date 01/01/2026, quoted in part, “Implementing Care and Treatment, … Purpose: To ensure patient/client care and treatment are provided as identified in the care planning process. … Procedure: … I. The Agency is responsible for patient/client care and must conduct and provide, either directly or under arrangement, all services rendered to patients/clients.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an EP plan that must be reviewed and updated at least every two years for one of one EP plan reviewed. This failure placed patients at risk of harm in the event of an emergency or disaster if the agency’s emergency plan was not effective. Findings include: Record review of the agency’s EP binder, undated, did not contain a review of the emergency response plan to evaluate its effectiveness and to update the plan as needed for calendar years 2023, 2024, or 2025. Also, the agency’s EP binder showed no evidence of an annual review being performed for calendar year 2026 as of 7/7/2026. Record review of the agency’s continuity of operations business plan, undated, reflected a disaster coordinator who is no longer employed with the agency. During the entrance conference with the Adm, DON, and Office Manager on 6/30/2026 at 2:30PM, the Adm stated that he is the Disaster Coordinator and the ADON is the Alternate Disaster Coordinator as of January 16, 2026. During an interview with the Adm, DON, ADON, and Office Manager on 7/8/2026 at 11:20AM, Surveyor asked why the agency failed to maintain an EP plan that must be reviewed and updated at least every two years and why the EP plan had not been updated to reflect management changes. Adm responded that there was a delay due to the transition in business operations. Surveyor asked why agency policies and regulations were not followed, and Adm stated that the agency had removed the management company in January 2026 and the agency is “getting situated with everything”. Agency policy EC.40 titled, “Emergency Preparedness and Response Plan”, revised 2/16/2026, read in part… “Policy…II. The Agency will have a written…plan…The plan will…E. Be reviewed and updated…at least every two years.” Agency policy EC.40-TX, titled “Emergency Preparedness and Response Plan”, revised 1/15/2026, read in part… “Policy I…A. The agency will…review…at least annually…and update the plan as needed.””

“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 electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the patient for 16.22% (714 of 4403) of assessments transmitted between 6/30/2025-6/30/2026 and 14.87% (127 of 854) of assessments transmitted between 4/6/2026-7/6/2026. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion date for analysis to identify agency performance levels in the provision of patient care. Findings include: During pre-survey activity on 6/30/2026: the Surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) for the period of 6/30/2025 – 6/30/2026. The report included 714 of 4403 OASIS assessments (16.22%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. During record review on 7/7/2026, the Surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES for the period of 4/6/2026-7/6/2026 to reflect the change in management, specifically the DON. The report included 127 of 854 OASIS assessments (14.87%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Adm/DON/ADON on 7/8/2026 at 10:55 AM. The DON stated that as of January 2026, RN B has been responsible for submitting OASIS assessments, and that the nurse who had done it previously was no longer with the agency. The Surveyor asked why 16.22% of OASIS assessments are being submitted after 30 days. The DON and ADON both responded that they were unsure. The Surveyor asked why agency policies and regulations were not followed, to which Adm replied that many changes had occurred within the agency and there was uncertainty during management changes. Review of agency policy IM.35 titled, “Timelines”, revised 1/1/2026, read in part…”Procedure II. All completed and encoded OASIS data will be transmitted…to CMS…within 30 days of the M0090 date.””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the agency to assess processes of care, services and operations for 10 of 10 QAPI meetings records reviewed. This failure could place patients at risk of the agency being unable to identify potential problems and implement corrective actions to ensure the health and safety of agency patients. The findings include: Record review of agency QAPI records revealed only one QAPI meeting for the calendar year 2023. The meeting dated 7/11/2023 did not include a review and update or revision of the QAPI plan of implementation. The meeting also failed to review the following regulatory requirements: medication administration and errors, the effectiveness/safety of services provided, if services were performed per the POC, and complaint and satisfaction survey data. Record review of the agency’s QAPI program for the calendar year 2024 demonstrated four meetings with the following completion dates: 8/19/2024, 10/29/2024, 1/29/2025, 7/7/2026. These meetings did not include a review and update or revision of the QAPI plan of implementation. The meeting with a completion date of 8/19/24 reviewed the agency’s 1st quarter of 2024 QAPI. This meeting failed to analyze a sample of services for active and closed records and failed to review the following regulatory requirements: complaints and incidents of unprofessional conduct, medication administration and errors, effectiveness/safety of services provided, and if services were performed per the POC. The meeting with a completion date of 10/29/24 reviewed the agency’s 2nd quarter of 2024 QAPI. This meeting failed to review the following regulatory requirements: complaints and incidents of unprofessional conduct, medication administration and errors, effectiveness/safety of services provided, and if services were performed per the POC. The meeting with a completion date of 1/29/2025 reviewed the agency’s 3rd quarter of 2024 QAPI. This meeting failed to review the following regulatory requirements: complaints and incidents of unprofessional conduct, medication administration and errors, effectiveness/safety of services provided, complaint and satisfaction surveys, and if services were performed per the POC. The meeting with a completion date of 7/7/2026 reviewed the agency’s 2nd quarter of 2024 QAPI. This meeting failed to analyze a sample of services for active and closed records and failed to review the following regulatory requirements: negative patient care outcomes, complaints and incidents of unprofessional conduct, medication administration and errors, effectiveness/safety of services provided, complaint and satisfaction survey data, and if services were performed per the POC. Record review of the agency’s QAPI program for the calendar year 2025 demonstrated four meetings with the following completion dates: 4/7/2026, 6/18/2025, 1/12/2026, and 2/19/26. These meetings did not include a review and update or revision of the QAPI plan of implementation. The meeting with a completion date of 4/7/2026 reviewed the agency’s 1st quarter of 2025 QAPI. This meeting failed to analyze a sample of services for active and closed records and failed to review the following regulatory requirements: negative patient care outcomes, complaints and incidents of unprofessional conduct, medication administration and errors, effectiveness/safety of services provided, complaint and satisfaction survey data, and if services were performed per the POC. The meeting with a completion date of 6/18/2025 reviewed the agency’s 2nd quarter of 2025 QAPI. This meeting failed to review the following regulatory requirements: medication administration and errors, effectiveness/safety of services provided, complaint and satisfaction survey data, and if services were performed per the POC. The meeting with a completion date of 1/12/2026 reviewed the agency’s 3rd quarter of 2025 QAPI. This meeting failed to analyze a sample of services for active and closed records and failed to review the following regulatory requirements: negative patient care outcomes, complaints and incidents of unprofessional conduct, medication administration and errors, effectiveness/safety of services provided, complaint and satisfaction survey data, and if services were performed per the POC. The meeting with a completion date of 2/19/2026 reviewed the agency’s 4th quarter of 2025 QAPI. This meeting failed to review the following regulatory requirements: medication administration and errors, effectiveness/safety of services provided, complaint and satisfaction survey data, and if services were performed per the POC. Review of the agency’s 2026 QAPI records reflected one meeting with a completion date of 7/2/2026. This meeting reviewed the agency’s 1st quarter QAPI information and did not include a review and update or revision of the QAPI plan of implementation. This meeting also failed to analyze a sample of services for active and closed records and failed to review the following regulatory requirements: medication administration and errors, effectiveness/safety of services provided, satisfaction survey data, and if services were performed per the POC. During an interview with the office manager, DON, ADON, and Adm on 7/8/2026 at 1055, Surveyor asked why the agency’s QAPI meetings did not review the information required by regulations. Adm responded that the agency is “regrouping” after leaving a management company. Surveyor asked when the agency moved away from using a management company and the ADON stated January of 2026. Surveyor asked if they were aware of the QAPI requirements and the Adm replied, “Yes, we are aware.” Surveyor asked why agency policies and regulations have not been followed regarding QAPI, ADON stated that it has been difficult to reorganize after the management changes. Agency policy QAPI.15 titled, “Performance Improvement Process: Data Collection”, revised 5/1/2024, read in part…”The Agency will routinely collect data related to…A. Services furnished…to active and discharged patients…B . negative…outcomes…C. Complaints…E. Medication administration and errors…F. Effectiveness and safety of all services provided…G. Services…performed as outlined in the…care plan…H…complaints and satisfaction survey data.””

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview the agency failed to integrate services provided by various disciplines, directly or under arrangement, to ensure the identification of patient needs and factors that could affect patient safety and treatment effectiveness. The agency failed to coordinate patient care in the following areas: Skilled nursing, Home Health Aides, PT, and a MSW visit for three of eighteen patient records reviewed (Patients 2, 3, and 4). This failure caused a delay in services and placed patient’s health and safety at risk due to inadequate care. Findings include: Patient 2: Review of Patient 2’s clinical record revealed a SOC of 3/27/25 with the diagnoses of Parkinsons Disease (a progressive brain disorder caused by the loss of dopamine-producing neurons), Dementia (an umbrella term for a decline in cognitive abilities—such as memory, reasoning, and communication—that is severe enough to impair daily life), and Epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain). Patient 2’s clinical record revealed three POCs dated as follows: 3/27/2025, 5/26/2025, and 7/25/2025. POC dated 3/27/2025, for the certification period of 3/27/2025 – 5/25/2025, included the following orders: SN once a week for nine weeks, PT evaluation and treatment, HHA once a week for one week then three times a week for eight weeks, and MSW one to two visits every sixty days. During this certification period, there is no evidence that Patient 2 received a MSW visit or a PT evaluation. POC dated 5/26/2025, for the certification period of 5/26/2025 – 7/24/2025, included the following orders: SN once a week for nine weeks, HHA three times a week for eight weeks then twice a week for one week, and MSW one to two visits every sixty days. During this certification period, Patient 2 received 5 out of 9 SN visits and had 6 missed SN visits with no documented attempts to reschedule. Record review failed to reveal evidence that Patient 2 received a MSW visit during this certification period. POC dated 7/25/2025, for the certification period of 7/25/2025 – 9/22/2025, included the following orders: SN once a week for nine weeks, PT evaluation and treatment, and HHA visits twice a week for eight weeks. During this certification period, Patient 2 received 6 out of 9 SN visits and had 3 missed SN visits with no documented attempts to reschedule. Patient 2 received 8 out of 16 HHA visits. The last HHA visit is dated 8/11/2025 and Patient 2’s record showed no evidence of attempts to reschedule or obtain another HHA. Record review failed to demonstrate a PT evaluation during this certification period. Patient 2 was discharged from the agency on 9/18/2025 per family request. From 3/27/2025 through 9/18/2025 there was no evidence of a MSW visit or a PT evaluation in the clinical record. During an interview with Adm, DON and ADON on 7/6/2026 at 1:39 PM, Surveyor asked why Patient 2 never received a PT evaluation or MSW. Adm responded that Patient 2 may have been higher acuity and that would be the reason for not sending PT. The DON stated that the therapy company declined because they had no coverage in Patient 2’s area. The DON continued to state that she did not see anything documented for the MSW but she assumed that the same therapy company did not have coverage in Patient 2’s area. Surveyor asked why Patient 2 had so many missed SN and HHA visits without documentation or attempts to reschedule, and why there were no HHA visits after 8/11/2025. The DON stated that she couldn’t find any documentation as to why Patient 2 had multiple missed visits. Surveyor asked why agency policies and regulations were not followed. The ADON stated that at that time, the agency was under a big management company, and they did not have much control. During a phone interview with RN A on 7/6/2026 at 3:43 PM, RN A stated that the agency kept telling her that they did not have an aide in Patient 2’s area. RN A stated that the agency couldn’t find service and the Patient’s family got frustrated. RN A continued to say the agency doesn’t follow through and they need to manage care better or transfer patients when they cannot provide the care that is ordered. RN A stated she reported the missing HHA visits to the agency but would get transferred to someone in India who only responded via text message and that other agencies RN A had worked for typically schedule patients within 24 hours. Patient 3: Review of Patient 3’s clinical record revealed a SOC of 6/7/2024 with the diagnoses of Lymphedema (a chronic condition causing tissue swelling from an accumulation of protein-rich lymph fluid) of both legs. The POC for the certification period 3/29/2026-5/27/2026 included an order for SN visits twice a week for nine weeks to assess and care for Patient 3’s bilateral lower extremity wounds. Record review revealed the first documented SN visit for this certification period was dated 4/10/2026. Therefore Patient 3 did not receive the first 3 SN visits. Further review of the clinical record failed to identify documentation explaining the reason the visits were not provided, rescheduled, or otherwise addressed by the agency. During an interview with Adm, DON and ADON on 7/6/2026 at 2:30 PM, Surveyor asked why Patient 3 missed three visits and why no documentation explaining the reason for the missed visits could be found. The DON responded that there should not have been a lapse in care and the authorization team was responsible for scheduling visits. The ADON mentioned that wound care patients no longer need to wait for an authorization to get scheduled. Surveyor asked where the authorization team is based out of and the Adm stated India. Surveyor asked why agency policies and regulations were not followed, to which the Adm stated that the authorization department wanted progress notes and that caused a delay in scheduling. Patient 4: Review of Patient 4’s clinical record revealed a SOC of 5/18/2026 and the diagnoses of Cardiomyopathy (a progressive disease of the heart muscle where it becomes enlarged, thick, or rigid), Kidney Disease (occurs when damaged organs cannot properly filter blood, leading to a dangerous buildup of waste and fluids), and Heart Failure (when the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body’s needs). The POC for the certification period 5/18/2026 – 7/16/2026 included orders for SN visits twice a week for one week then three times a week for eight weeks, and HHA visits once a week for one week then twice a week for eight weeks. As of 7/6/2026, Patient 4 received two HHA visits (5/18/26 and 5/26/26). Review of Patient 4’s clinical record failed to demonstrate attempts to contact the client or doctor regarding the agency’s inability to schedule HHA visits. During a phone interview with CNA A on 7/6/22 at 1530, Surveyor asked if CNA A had provided care for Patient 4. CNA A stated that she did not visit the patient. Surveyor stated the last documented note from CNA A for Patient 4 was dated 5/26/2026, to which CNA A replied, “then that’s the last time I saw” Patient 4. CNA A continued to say that Patient 4’s family member did not answer calls or texts for the next two scheduled visits. Surveyor asked CNA A why there was no documentation of these attempts to visit Patient 4 and CNA A responded that the scheduling team was notified. During an interview with the Adm and ADON on 7/6/2026 at 4:22 PM, Surveyor asked why Patient 4 had not received the HHA visits as ordered. The ADON responded that the HHA did not complete the visit notes and continued to say that the agency would have been notified or would have received a complaint if the HHA visits were not being provided. Surveyor asked why agency policies and regulations have not been followed regarding the coordination of care. The Adm replied that “it very rarely happens” and continued to state that when care cannot be provided then the agency notifies the doctor and client to make sure they were aware that services cannot be provided. Review of agency policy PC.30 titled, “Orders for Care”, revised 1/1/2026, read in part…”The agency will obtain orders and provide care in accordance with physician’s or allowed practitioner’s orders…”. Review of agency policy PC.35 titled, “Plan of Care”, revised 1/1/2026, read in part…”Procedure V. Each patient/client must receive the home health services that are written in an individualized Plan of Care…”. Review of agency policy PC.40 titled, “Implementing Care and Treatment”, revised 1/1/2026, read in part…”Procedure I. The agency is responsible…and must conduct and provide, either directly or under arrangement, all services rendered to patients/clients.” Review of agency policy PC.45 titled, “Monitoring Patient/Client Care/Coordination of Care”, revised 1/1/2026, read in part…”Policy II. The agency will collaborate with other organizations providing services…to ensure appropriate coordination of care…Procedure 1. The agency will…B…assure the coordination of all services…provided to the patient/client.””

“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, all skilled profession staff much provide input into and participate in the agency’s QAPI program, for 8 of 10 QAPI meetings reviewed, in that: there was no evidence that other skilled professionals gave input according to the agency’s policy. This failure placed agency patients at risk by limiting the agency’s ability to effectively evaluate, monitor, and improve the quality and safety of all services provided. Findings include: Record review of the agency’s QAPI program for the calendar year 2024 demonstrated four meetings with the following completion dates: 8/19/2024, 10/29/2024, 1/29/2025, and 7/7/2026. The meeting with a completion date of 8/19/24 reviewed the agency’s 1st quarter of 2024 QAPI. The document pertaining to this meeting was only signed by the Adm, no other members are mentioned. The meeting with a completion date of 10/29/24 reviewed the agency’s 2nd quarter of 2024 QAPI. The document pertaining to this meeting was only signed by the Adm, no other members are mentioned. The meeting with a completion date of 1/29/2025 reviewed the agency’s 3rd quarter of 2024 QAPI. The document pertaining to this meeting was only signed by the Adm, no other members are mentioned. The meeting with a completion date of 7/7/2026 reviewed the agency’s 2nd quarter of 2024 QAPI. The document pertaining to this meeting was only signed by a SN who is no longer employed with the agency, no other members are mentioned. Record review of the agency’s QAPI program for the calendar year 2025 demonstrated four meetings with the following completion dates: 4/7/2026, 6/18/2025, 1/12/2026, and 2/19/26. The meeting with a completion date of 4/7/2026 reviewed the agency’s 1st quarter of 2025 QAPI. The document pertaining to this meeting was only signed by a SN who is no longer employed with the agency, no other members are mentioned. The meeting with a completion date of 6/18/2025 reviewed the agency’s 2nd quarter of 2025 QAPI. The document pertaining to this meeting was signed by the Adm and a SN who is no longer employed with the agency, no other members are mentioned. The meeting with a completion date of 1/12/2026 reviewed the agency’s 3rd quarter of 2025 QAPI. The document pertaining to this meeting was signed by the Adm and the ADON, no other members are mentioned. Review of the agency’s 2026 QAPI records reflected one meeting with a completion date of 7/2/2026. The document pertaining to this meeting was signed by the Adm and the ADON, no other members are mentioned. During the entrance conference on 6/20/2026 at 2:30 PM the Adm stated a healthcare consultant company is responsible for QAPI activities and that the committee included the Adm, Alt Adm, DON, and ADON. During an interview with the DON on 7/7/2026 at 12:09PM, Surveyor asked who was on the QAPI Committee, DON replied “I guess I’m supposed to be on it, but I’m not really sure.” During an interview with the office manager, DON, ADON, and Adm on 7/8/2026 at 1055, Surveyor asked why the agency’s QAPI Committee did not contain the members required by regulations and the agency’s policy. Adm responded that the agency was “regrouping” after leaving a management company. Surveyor asked when the agency moved away from using a management company and the ADON stated January of 2026. Surveyor asked if they were aware of the QAPI requirements and the Adm replied, “Yes, we are aware.” Surveyor asked why agency policies and regulations have not been followed regarding QAPI Committee composition requirements. The ADON stated that it has been difficult to reorganize after the management changes. Agency policy QAPI.5-TX titled, “Quality Assessment Performance Improvement Program – Addendum”, revised 4/14/2023, read in part…”B. 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.””