Every finding on record at Angels at Home Inc

A recertification survey was conducted on 03/24/2025. The census was: L&CHHS: 11 LHHS: 0 PAS: 111 The agency is in substantial compliance with no deficiencies cited.

A recertification survey was conducted on 03/24/2025. The census was: L&CHHS: 11 LHHS: 0 PAS: 111 Abbreviations/Acronyms: HHA: Home Health Agency L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services PAS: Personal Assistance Services SN: Supervising Nurse QAPI: Quality Assessment and Performance Improvement

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 interview and record review, the HHA failed to show measurable improvement in indicators to improve health outcomes, patient safety, and quality care, by failing to evaluate the QAPI program for 3 of 3 years reviewed (2022, 2023, and 2024). Failure of the HHA to complete an evaluation of measurable outcomes as part of their QAPI program placed the agency's clients at risk of inadequate care and services due to the agency's inability to trend patterns and to implement improved client services. Findings included: During a record review at 1:34 PM on 3/24/25, Surveyor reviewed the binder labeled, “QAPI” (undated). No measurable improvement or evaluations of the total operation of the HHA, and no evaluation of contract services were included in the binder for the last 3 of 3 years (2022, 2023, 2024). During an interview at 1:54 PM on 3/24/25, Surveyor B asked SN/Owner if they have annual evaluation as part of their QAPI program. SN stated that she did not realize that was supposed to be included in the QAPI program. Surveyor B asked if they had any other documentation related to QAPI other than what was in the binder. SN/Owner stated they did not. During an interview at 2:50 PM on 3/24/25, Surveyor B asked SN/Owner who was responsible for the QAPI program. SN/Owner stated, “I am.” Surveyor B asked what the reason was for the failure of documenting measurable indicators and evaluating the QAPI program. SN/Owner stated she did not realize that was a requirement and said, “everything is a learning experience.” Surveyor asked how not assessing agency performance could affect client care. SN/Owner stated that “anytime you review anything it makes us better” and stated that this process should, in fact, affect client care because “it should make us better nurses”. During a joint interview with the Administrator and SN/Owner at 2:03 PM on 3/26/25, Surveyor B asked the administrator if she was aware of the HHA’s failure provide measurable improvement data in the form of evaluations as part of the QAPI program. At this time, SN/Owner reported the failing to the administrator. The administrator nodded and said, “Okay.” The administrator had nothing else to add. During a record review of the agency’s policies, a policy titled, “Quality Assessment/Performance Improvement Plan,” undated, read in part, “The governing body is responsible for ensuring…that the agency wide QAPI efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.” During a record review of the agency’s policies, an additional policy titled, “Quality Assessment and Performance Improvement (QAPI) Program,”, undated, read in part, “The QAPI committee will meet at least twice a year or more often if needed. All programs administered by [the agency] are evaluated.”