Ameristars Best Care Inc.

“Based on interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects for 3 of 3 (2021, 2022, and 2023) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the agencys program for which performance could be improved. The findings included: Review of the documentation regarding the agencys Quality Assessment Performance Improvement Plan (QAPI) Program included no documentation to indicate the agency had developed, implemented, or evaluated a performance improvement project for the years 2021, 2022, and 2023. During an interview on 05/15/2024 at 11:35 AM, with the Administrator, the surveyor reviewed and discussed the above findings. The surveyor asked who was responsible for the QAPI program. The Administrator said, “;I am. We didnt do performance improvement projects. We were focusing on ADRs (Additional Records Requested) from Medicare. We were focusing on trying to stay in business.” Agency policy titled “QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI.1” revised 010118 read in part: “...PURPOSE To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement Plan (QAPI) ... POLICY I. The Agency will develop, implement, evaluate, and maintain an effective, ongoing, hospice-wide data-driven QAPI plan that is evaluated, reviewed, and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee...V. Areas for improvement will be identified through the collection of data for analysis of Agency services... PROCEDURE...X. The Agency will develop, implement, and evaluate Performance Improvement Projects PIPs) based on the needs of the agencys population and internal organization needs. The projects will reflect the scope, complexity, and past performance of the Agencys services and operations. A. The Agency must document what PIPs are being conducted, the reasons for conducing these projects. B. The agency must document corrective action to ensure that improvements are sustained over time...””

“Based on record review and interviews, the agency failed to ensure the agency maintained a Quality Assessment Performance Improvement Plan (QAPI) Program for 2 (2022 and 2023) of 3 years reviewed. This failure could prevent the agency from monitoring the effectiveness and safety of agency services provided to the agency’s patients. The failure could also prevent the agency from identifying problems, implementing corrective actions to ensure the health and safety of the agency’s patients, and if necessary, revise policies. The findings included: QAPI binder review: 1. The binder did not contain an annual evaluation of the QAPI program for 2022 and 2023. 2. The binder did not contain any reports, reviews nor documentation that indicated the agency had maintained an QAPI program that included the regulatory requirements, for the years 2022 and 2023. The binder did not indicate that the agency had conducted: 1. An analysis of a representative sample of services furnished to patients contained in both active and closed records; 2. A review of negative patient care outcomes; 3. A review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff; 4. A review of infection control activities; 5. A review of effectiveness and safety of all services provided, including: (-a-) the competency of the agency’s clinical staff; (-b-) the promptness of service delivery; and (-c-) the appropriateness of the agency’s responses to patient complaints and incidents; 6. A determination that services had been performed as outlined in the individualized service plan, and 7. An analysis of patient complaint and satisfaction survey data; and 8. An annual evaluation of the total operation, including services provided under contract or arrangement. (-a-) Used the evaluation to correct identified problems and, if necessary, revised policies. (-b-) Documentation of corrective action that ensured improvements were sustained over time. During an interview on 05/15/2024 at 11:33 AM, with the Administrator, the surveyor reviewed and discussed the above findings. The surveyor asked who was responsible for the QAPI program. The Administrator said, “ I am. We didnt do chart or reviews. We were focusing on ADRs (Additional Records Requested) from Medicare. We were focusing on trying to stay in business.” Agency policy titled “QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI.1” revised 010118 read in part: “...PURPOSE To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement Plan (QAPI) ... POLICY I. The Agency will develop, implement, evaluate, and maintain an effective, ongoing, hospice-wide data-driven QAPI plan that is evaluated, reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee...V. Areas for improvement will be identified through the collection of data for analysis 0f Agency services. Systems that measure significant outcomes for optimal care include: A. A representative sample of services furnished to patients contained in both active and discharged charts; B. Negative client care outcomes; C. Issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff; D. Infection control activities; E. Medication administration and errors; F. Services have been performed as outlined in the plan of care; G. Patient complaints and satisfaction survey data, including Agency response to complaints; H. Annual evaluation of total operations, including services under contract; I. Patient incidents including agency response to incidents; J. Effectiveness and safety of all services provided including: 1. Competency of Agency staff, 2. Promptness of service delivery ... PROCEDURE...XI. QAPI documents will be kept confidential and be made available to state hospice licensing staff upon request...””