Every finding on record at A-Prime Medical Home Health, Inc.

A recertification was conducted on 6/8/2026. The census was: L&CHH: 3 LHH: 0 Abbreviations/Acronyms: L&CHH: Licensed and Certified Home Health LHH: Licensed Home Health The agency had no deficiencies cited.

A recertification was conducted on 6/8/2026. The census was: L&CHH: 3 LHH: 0 Abbreviations/Acronyms: L&CHH: Licensed and Certified Home Health LHH: Licensed Home Health HHA: Home Health Agency QAPI: Quality Assurance and Performance Improvement

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 included: 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 and Office Manager on 6/9/2026 at 12:45 PM, the Administrator and Office Manager were asked what the agency’s performance improvement projects were for the years under review (2023, 2024 and 2025), and Administrator and Office Manager were unsure what was being asked. Surveyor explained in the QAPI binder provided by the agency, the surveyor was able to see the quarterly meetings conducted by the agency, but there was no documentation for any completed, ongoing or in development performance improvement projects. Surveyor asked if they had any documentation showing these activities and the Office Manager stated they were unsure when it became a requirement for performance improvement projects. The Surveyor reviewed the State Operation Manual, Appendix B (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_b_hha.pdf) under G658 (Rev. 219; Issued: 04-12-24; Effective: 04-12-24; Implementation: 04-12-24) §484.65(d) Standard: Performance improvement projects which read in part “Beginning January 13, 2018 HHAs must conduct performance improvement projects.” The Administrator and Office Manager were unable to provide documentation which supported the quality improvement projects undertaken, reasons the projects were conducted, and the measurable progress achieved on these projects. The Surveyor asked whose responsibility it was to ensure the performance improvement projects were completed, and the Administrator stated it was the administrator’s responsibility. Surveyor asked why it was important to patient care to have yearly performance improvement projects, and the Administrator stated it was “important to identify issues that the agency was having and work on it and then go back to check on what was done had any measurable effect.” Review of Agency’s Administrative Policy (copyright 2014) under section 8.6 “Quality Assessment and Performance Improvement Initiatives” reads in part “As an Agency seeking to provide the highest quality of care and customer satisfaction, we must effectively design a quality improvement program that systematically measures, assesses and improves the performance of the quality of care and services provided by the agency. The design emphasizes the importance of the Agency affecting its best efforts to create appropriate processes and functions required to achieve improved client health outcomes and customer satisfactions.” Further review of the Agency’s Administrative Policy (copyright 2014) did not reveal any specific policy outlining performance improvement project requirements.