Royalty Care 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 a performance improvement project, either in development, on-going, or completed, within the calendar year in 3 (2023, 2024, and 2025) of 3 years reviewed. Failure of the agency to complete a performance improvement project resulted in a missed opportunity to improve upon an area of weakness and improve agency functioning and patient care. Findings include: Per record review of the agency’s QAPI binder for years 2023, 2024 and 2025 there was no documentation found of any performance improvement projects outlining steps planned for improvement, goals, or evaluation criteria. In an interview with the Administrator on 5/6/2026 at 10:45 AM, Surveyor 1 asked Administrator what the agency’s performance improvement projects were for the years under review (2023, 2024 and 2025), and Administrator was unsure what was being asked. Surveyor 1 explained in the QAPI binder provided by the agency, the surveyors were able to see the data collected on quality indicators, but there was no documentation for any completed, ongoing or in development performance improvement projects. In addition, there was no documented “quality improvement projects undertaken, the reason for conducting these projects, and the measurable progress achieved on these projects” as stated in the agency policy (below). Surveyor 1 asked if they had any documentation showing these activities and the Administrator confirmed she did not have that. Surveyor 1 asked the administrator why it was important to patient care to have yearly performance improvement projects. The Administrator stated it was important to make sure patients received the care they needed, reduce hospitalizations, reduce patient falls, and ensure the patients are being taken care of. Review of agency’s Administrative Policy Manual, last review date of 050124, Section titled “Quality Assessment Performance Improvement (QAPI)”, under section QAPI.5 “Quality Assessment Performance Improvement Program”, reads in part under section III. “The QAPI Plan will be developed based on…E. Performance Improvement projects…2. The agency will document the quality improvement projects undertaken, the reason for conducting these projects, and the measurable progress achieved on these projects.”. Further review revealed under section QAPI.25 “Performance Improvement Process: Improvement Activities”, under “Policy” reads “I. The Governing Body will be responsible for setting priorities for improvement activities or projects based on Agency functions, the defined data collection, the resources required to facilitate the improvement, and the organization’s mission. II. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually. III. When developing and prioritizing the improvement activities or projects, the Governing Body will consider the following: A. The scope, complexity, and past performance of the Agency’s services and operations; B. The expected impact of the improvement on performance, patient/client outcomes and safety; C. High-risk, high-volume, or problem-prone areas of service to include the incidence, prevalence, and severity of problems in those areas; D. Data obtained from OASIS generated reports (i.e., OBQM, PBQM and OBQI); E. Previous problematic issues where there is clear evidence of poor patient/client outcomes; and F. Agency resources. IV. All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved.” Further review reveals under section “Procedure” reads “I. Areas for improvement will be identified through data collection, aggregation, and analysis. II. The staff members with the greatest working knowledge of the process will be actively involved in the improvement process. III. The performance improvement activity strategy for change will be designed and implemented with appropriate Agency staff and other resources involved. IV. Agency staff affected by the change will be educated. V. The strategy for change will be tested on a trial basis. VI. Data will be collected to assess if improvement occurred as a result of the strategy for change. VII. If appropriate, the change will be implemented Agency-wide. VIII. Performance measures will be used to determine if the improvement is sustained.””