Every finding on record at Best Providercare Services Inc

A relicensure/recertification survey entrance conference was conducted with the Adm/DON on 08/27/2024 at 2:00 PM. Census: LCHHS: 10 LHHS: 0 PAS: 56 An exit conference was conducted with the Adm/DON and the PAS Sup on 08/30/2024 at 3:00 PM. The preliminary findings were discussed. The agency was found in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A relicensure/recertification survey entrance conference was conducted with the Adm/DON on 08/27/2024 at 2:00 PM. Census: LCHHS: 10 LHHS: 0 PAS: 56 An exit conference was conducted with the Adm/DON and the PAS Sup on 08/30/2024 at 3:00 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: % - percent Adm – Administrator Att - attendant CMS - Centers for Medicare & Medicaid Services DADS - Texas Department of Aging and Disability Services (now known as Texas Health and Human Services Commission) DON - Director of Nurses HHA – home health agency IQIES - IQIES - Internet Quality Improvement and Evaluation System LCHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services LVN – licensed vocational nurse OASIS - Outcome and Assessment Information Set PAS- Personal Assistance Services PM - Post meridiem TDFPS - Texas Department of Family and Protective Services

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 beneficiary (patient) for 27.59% (32 of 116) of assessments transmitted during 08/24/2023-08/24/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 08/24/2024: 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) during the one-year of 08/24/2023-08/24/2024. The HHA Error Summary by Agency report included 32 of 116 OASIS assessments (27.59%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Adm/DON on 08/27/2024 at 2:00 PM. The Adm/DON stated she was responsible for submitting OASIS assessments to the CMS system. An interview was conducted with the Adm/DON on 08/30/2024 at 1:09 PM and the surveyor reviewed the error summary report which included 32 OASIS assessments submitted late. The Adm/DON stated during the period under review, she frequently traveled out of the country. When the Adm/DON logged in to the system outside the United States, it could not be accessed. The Adm/DON thought some OASIS assessments had been submitted, but later looked and noticed the assessments had not been submitted, did not know why they were not submitted, and was mad when she discovered it, which resulted in the agency not following its policy. Agency Policy titled, "Timelines IM.35" with a revision date of 05/02/2024, read in part, “…Purpose To establish timely parameters for all medical record information… Procedure… II. All completed and encoded OASIS data will be transmitted… to the CMS collection site within 30 days of the M0090 date…”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to follow their agency policy to ensure notes were written on the day of service and incorporated into the patient record within 14 days in two of seven records reviewed (Patient 2 and 3) who received skilled nursing services. This failure placed the agency patients at risk of not receiving the appropriate care and services due to their current health status not being incorporated into the records. Findings included: Agency Policy titled, "Timelines IM.35" with a revision date of 05/02/2024, read in part, “…Procedure I. Agency staff, physician(s) and/or non-physician practitioner(s) and physician office staff, as appropriate, will be oriented to the following parameters… D. Daily progress notes with correlating time sheets are turned in within a maximum of seven calendar days… IV. All medical record information will be incorporated into the patient's/patient’s medical record in a timely manner…” Agency Policy titled, " Timelines – Addendum IM.35-TX" with a revision date of 04/14/2023, read in part, “…Procedure I. In addition to the requirements defined in the Timelines policy in the Management of Information section of the Administrative Policy Manual, the following requirements will also be met: A. All clinical and progress notes will be written the day service is rendered. B. All medical record information will be incorporated into the patient’s/client’s medical record within 14 working days…” Patient 2: Record review of the electronic health record included a plan of care dated 05/10/2024 to 07/08/2024 that was electronically signed by the Adm/DON. The plan of care included an order for a nurse to visit the client one time a week for nine weeks. The electronic record included a calendar of scheduled visits for LVN on 05/11/2024 and 05/17/2024. The visit note scheduled for 05/11/2024 was dated 05/09/2024 and did not include the visit start and end time, vital signs, and LVN’s electronic signature. The visit note dated 05/17/2024 did not include the visit start and end time and LVN’s electronic signature. During a phone interview with LVN on 08/30/2024 at 12:43 PM, the surveyor asked if the scheduled visit on 05/11/2024 was conducted on 05/09/2024 and why the visit notes dated 05/09/2024 and 05/17/2024 were incomplete. LVN stated the visit was conducted on 05/11/2024. The LVN stated during the interview, he opened the electronic health record and both visit notes were completed. During the interview, the surveyor again reviewed the visit notes in the electronic health record and both had been completed since the surveyor review on 08/29/2024. The surveyor asked when the visit notes were completed. LVN stated two days ago. [LVN] stated he had an accident in May and could not complete the notes at that time. Patient 3: Record review of the electronic health record included a plan of care dated 06/04/2024 to 08/02/2024 that was electronically signed by the Adm/DON. The plan of care included an order for a nurse to visit the patient three times a week for four weeks then one time a week for five weeks. The electronic record included a nurse visit note conducted by the Adm/DON on 07/03/2024 that was not electronically signed or dated. The record did not include nurse visit notes for the four weeks of 07/07-07/13/2024, 07/14-07/20/2024, 07/21-07/27/2024 and 07/28-08/02/2024. One nurse visit was ordered for each of the four weeks. During an interview with the Adm/DON on 08/28/2024 at 1:20 PM, the surveyor asked why the nurse visit note dated 07/03/2024 was not electronically signed and dated. The Adm/DON stated she did not know. During an interview with the Adm/DON on 08/28/2024 at 3:30 PM, the surveyor asked why weekly nurse visit notes were not completed starting the week of 07/07/2024. The Adm/DON stated the nurse visit notes would not upload in the electronic health record due to an error within the system. The Adm/DON stated she received an email from the electronic health record vendor on 08/27/2024 stating the problem was fixed and the Adm/DON was now working on completing the nurse visit notes. The Adm/DON stated she was responsible for ensuring clinical visit notes were completed on the day of service and ensuring the notes were placed into the patient records within 14 working days. The Adm/DON stated agency policies were not followed because of the issues they were having. During an interview with the Adm/DON on 08/30/2024 at 1:22 PM, the surveyor asked why the nurse visit notes were not documented on paper since there was a problem with the electronic health record. The Adm/DON stated she should have written the notes on paper.

Purpose of Visit: Recertification Survey & Follow up to 04/25/2018 Entrance Date: 08/18/2021 Census: L&C - 27 LHH - 0 PAS - 50 The Best Healthcare Services Agency is in compliance with 42 CFR Part 484, Requirements for Home Health Agencies.

Purpose of Visit: Recertification Survey & Follow up to 04/25/2018 Entrance Date: 08/18/2021 Census: L&C - 27 LHH - 0 PAS - 50

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed and immediately corrected identified problems that directly or could potentially threaten the patient care and safety, in that the Agency did not have or complete a Performance improvement Project from 08/20/2018 to 08/20/2021. G-642 - Program Scope Based on record review and interview, the agency failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal patient care outcomes from 08/20/2018 to 08/20/2021. G-654 - Track Adverse Patient Events Based on record review and interview, the agency failed to implement Performance improvement activities that track adverse patient events, analyze their causes, and implement preventative actions. The agency failed to implement a Performance improvement activity to ensure optimal patient outcomes from 08/20/2018 to 08/20/2021. G-0660; Executive Responsibility for QAPI Based on record review and interview, the agency's Governing Body failed to ensure that the Quality Assessment Performance Improvement (QAPI) Committee met at least twice a year from 08/20/2018 to 08/20/2021 to make sure that an ongoing program for quality improvement and patient safety was defined implemented and maintained.

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 implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal patient care outcomes from 08/20/2018 to 08/20/2021. This failure could place the patients at risk of receiving inadequate care and services due to the agency not being able to trend patterns in issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff, client complaints, the agency's response to complaints, competency of care and client incidents and occurrences and/or the agency response to incidents and occurrences. The findings include: Review of the agency policy titled, "Quality Assessment Performance Improvement Plan", with a revision date of 01/29/2020, included, "The Agency will develop, implement and maintain an effective ongoing HHA-wide, data driven Quality Assessment Performance Improvement Plan (QAPI) program ... The Agency will maintain documentary evidence of the QAPI program and will be able to demonstrate the program operation to CMS. Program Scope: 1. The Program will show measurable improvement in indicators for which there is evidence that improvement in the indicators will improve health outcomes, patient safety and quality of care. 2. The Agency will measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the Agency to assess processes of care, Agency services and operations ..." At the Entrance conference on 08/18/21 at 11:59 a.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/18/21 at 5:35 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation be available the morning of 08/19/2021. At approximately 9:20 a.m. on 08/19/2021, with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation once again. In the afternoon on 08/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation for the fourth time. During an interview conducted on 8/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing when presented with the findings of if there was a QAPI manual/documentation she replied, " I guess you will just have to cite me because I do not have a QAPI manual because I have not done any QAPI." When asked if she had any QAPI activities that she could show. She said, "No. I have done some chart audit's, but I do not write anything down." When asked if she had done any QAPI at all since the last survey she replied, "No I have not. I had thought I would call a consultant to help me, but I have not done that either." The Surveyor requested a statement be written stating she did not have a QAPI program from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/19/21 at 5:00 p.m., with the Administrator/Director of Nursing, the Surveyor requested the statement for QAPI documentation be available the morning of 08/20/2021. During an interview conducted on 8/20/2021 at 9:05 a.m., with Administrator/Director of Nursing, when asked if she had the statement that was requested yesterday regarding the QAPI documentation from 08/20/2018 to 08/20/2021. She replied, "No I did not want to write it, so I stayed up all night putting this manual together." Surveyor reviewed the manual of QAPI documentation. Documentation was for years 2019, 2020 & currently 2021. It did contain the following: " Board of Directors minutes of meeting for Agency on February 19, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on April 15, 2020 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on February 27, 2021 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 11, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for January 4, 2020 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for January 4, 2020 with no signatures. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. " QAPI Committee minutes for January 14, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for July 10, 2020 with signatures of the Administrator & the alternate Administrator. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. " QAPI Committee minutes for July 15, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Tabletop & Annual Evaluation for Emergency Preparedness Plan for Covid 19 dated December 29, 2020 - no signatures. This should have been in the emergency preparedness manual. It discussed some Covid 19 issues. No QAPI mentioned in report. " QAPI Committee minutes for January 4, 2021 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 30, 2021 with no signatures. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation) & the four discharges that are mentioned on the report with their discharge dates are not on the discharge list provided to surveyor. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature typed in and not signed. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation). It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. During an interview conducted on 8/20/2021 at 9:18 a.m., with Administrator/Director of Nursing, when asked if there were QAPI documents for the year of 2018 she replied, "I do not have them." Surveyor requested for her to write a statement saying she did not have any QAPI documentation for the year 2018. She replied, "ok". Surveyor received the statement that Administrator/Director of Nursing typed, signed and dated 8/20/2021. In summary the agency did not follow the regulations or their own policy for QAPI. They did not develop, implement and maintain an ongoing agency wide, data driven Quality Assessment Performance Improvement Plan (QAPI) program. The Agency did not maintain documentary evidence of the QAPI program and was not able to demonstrate the program. The Program did not show measurable improvement in indicators for which there is evidence that improvement in the indicators will improve health outcomes, patient safety and quality of care. The Agency did not measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the Agency to assess processes of care, Agency services and operations.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to implement Performance improvement activities that track adverse patient events, analyze their causes, and implement preventative actions. The agency failed to implement a Performance improvement activity to ensure optimal patient outcomes from 08/20/2018 to 08/20/2021. This failure could place the agency's patients at risk of receiving inadequate care and services from the agency's inability to track adverse events, analyze their causes and implement preventative actions and the agency's inability to implement measures to improve its services to its patients. The findings include: Review of the agency policy titled, "Quality Assessment Performance Improvement Plan", with a revision date of 01/29/2020, included, "The Agency will develop, implement and maintain an effective ongoing HHA-wide, data driven Quality Assessment Performance Improvement Plan (QAPI) program ... The Agency will maintain documentary evidence of the QAPI program and will be able to demonstrate the program operation to CMS ... 2. The Agency will measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the Agency to assess processes of care, Agency services and operations ... Program Activities: 1. The Agency's Performance improvement activities will: a. Focus on high risk, high volume, or problem prone areas b. Consider incidence, prevalence, and severity of problems in those areas c. Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients 2. Performance improvement activities must track adverse patient events, analyze their causes and implement preventative actions ..." At the Entrance conference on 08/18/21 at 11:59 a.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/18/21 at 5:35 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation be available the morning of 08/19/2021. At approximately 9:20 a.m. on 08/19/2021, with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation once again. In the afternoon on 08/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation for the fourth time. During an interview conducted on 8/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing when presented with the findings of if there was a QAPI manual/documentation she replied, " I guess you will just have to cite me because I do not have a QAPI manual because I have not done any QAPI." When asked if she had any QAPI activities that she could show. She said, "No. I have done some chart audit's, but I do not write anything down." When asked if she had done any QAPI at all since the last survey she replied, "No I have not. I had thought I would call a consultant to help me, but I have not done that either." The Surveyor requested a statement be written stating she did not have a QAPI program from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/19/21 at 5:00 p.m., with the Administrator/Director of Nursing, the Surveyor requested the statement for QAPI documentation be available the morning of 08/20/2021. During an interview conducted on 8/20/2021 at 9:05 a.m., with Administrator/Director of Nursing, when asked if she had the statement that was requested yesterday regarding the QAPI documentation from 08/20/2018 to 08/20/2021. She replied, "No I did not want to write it, so I stayed up all night putting this manual together." Surveyor reviewed the manual of QAPI documentation. Documentation was for years 2019, 2020 & currently 2021. It did contain the following: " Board of Directors minutes of meeting for Agency on February 19, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on April 15, 2020 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on February 27, 2021 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " QAPI Committee minutes for July 11, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " QAPI Committee minutes for January 4, 2020 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " QAPI / Utilization Review Report for January 4, 2020 with no signatures. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " QAPI Committee minutes for January 14, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " QAPI / Utilization Review Report for July 10, 2020 with signatures of the Administrator & the alternate Administrator. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " QAPI Committee minutes for July 15, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " Tabletop & Annual Evaluation for Emergency Preparedness Plan for Covid 19 dated December 29, 2020 - no signatures. This should have been in the emergency preparedness manual. It discussed some Covid 19 issues. No QAPI mentioned in report. " QAPI Committee minutes for January 4, 2021 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " QAPI Committee minutes for July 30, 2021 with no signatures. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation) & the four discharges that are mentioned on the report with their discharge dates are not on the discharge list provided to surveyor. It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature typed in and not signed. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation). It does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. During an interview conducted on 8/20/2021 at 9:18 a.m., with Administrator/Director of Nursing, when asked if there were QAPI documents for the year of 2018 she replied, "I do not have them." Surveyor requested for her to write a statement saying she did not have any QAPI documentation for the year 2018. She replied, "ok". Surveyor received the statement that Administrator/Director of Nursing typed, signed and dated 8/20/2021. In summary the agency did not follow the regulations or their own policy for QAPI. The documentation does not indicate the agency tracked adverse patient events, analyzed their causes, and implemented preventative actions to assess care services and operations of the agency. The Agency did not maintain documentary evidence of the QAPI program and was not able to demonstrate the program. The Agency did not focus on high risk, high volume or problem with prone areas. The agency did not consider incidence, prevalence, and severity of problems in those areas. The agency did not do corrections of any identified problem that directly or potentially threaten the health and safety of patients. The Agency did not measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that enable the Agency to assess processes of care, Agency services and operations.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's Governing Body failed to ensure that the Agency developed, implemented and maintained a Quality Assessment Performance Improvement program to ensure an ongoing program for quality improvement and patient safety was defined implemented and maintained from 08/20/18 to 08/20/21. This failure could place the agency's patients at risk of receiving inadequate care and services from the agency's inability to trend patterns of competency of staff, services provided, promptness of service delivery and the agency's inability to implement measures to improve its services to its patients. The findings include: Review of the agency policy titled, "Quality Assessment Performance Improvement Plan", with a revision date of 01/29/2020, included, "The Agency will develop, implement and maintain an effective ongoing HHA-wide, data driven Quality Assessment Performance Improvement Plan (QAPI) program ... The Agency will maintain documentary evidence of the QAPI program and will be able to demonstrate the program operation to CMS ... The Agency's governing body is responsible for ensuring the following: 1. An on-going program for quality improvement and patient safety is defined, implemented and maintained 2. The Agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness ... 7. The governing board will assemble a QAPI working team that consists of the Administrator, supervising nurse or therapist, clinical coordinator and individuals representing the scope of services provided by the agency ... Program Procedure: ... The program will be evaluated, reviewed, and updated or revised at least twice within the calendar year, or more often if needed, by the governing board." At the Entrance conference on 08/18/21 at 11:59 a.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/18/21 at 5:35 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation be available the morning of 08/19/2021. At approximately 9:20 a.m. on 08/19/2021, with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation once again. In the afternoon on 08/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation for the fourth time. During an interview conducted on 8/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing when presented with the findings of if there was a QAPI manual/documentation she replied, " I guess you will just have to cite me because I do not have a QAPI manual because I have not done any QAPI." When asked if she had any QAPI activities that she could show. She said, "No. I have done some chart audit's, but I do not write anything down." When asked if she had done any QAPI at all since the last survey she replied, "No I have not. I had thought I would call a consultant to help me, but I have not done that either." The Surveyor requested a statement be written stating she did not have a QAPI program from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/19/21 at 5:00 p.m., with the Administrator/Director of Nursing, the Surveyor requested the statement for QAPI documentation be available the morning of 08/20/2021. During an interview conducted on 8/20/2021 at 9:05 a.m., with Administrator/Director of Nursing, when asked if she had the statement that was requested yesterday regarding the QAPI documentation from 08/20/2018 to 08/20/2021. She replied, "No I did not want to write it, so I stayed up all night putting this manual together." Surveyor reviewed the manual of QAPI documentation. Documentation was for years 2019, 2020 & currently 2021. It did contain the following: " Board of Directors minutes of meeting for Agency on February 19, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on April 15, 2020 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on February 27, 2021 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 11, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for January 4, 2020 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for January 4, 2020 with no signatures. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. " QAPI Committee minutes for January 14, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for July 10, 2020 with signatures of the Administrator & the alternate Administrator. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 15, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Tabletop & Annual Evaluation for Emergency Preparedness Plan for Covid 19 dated December 29, 2020 - no signatures. This should have been in the emergency preparedness manual. It discussed some Covid 19 issues. No QAPI mentioned in report. " QAPI Committee minutes for January 4, 2021 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 30, 2021 with no signatures. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation) & the four discharges that are mentioned on the report with their discharge dates are not on the discharge list provided to surveyor. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature typed in and not signed. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation). It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. During an interview conducted on 8/20/2021 at 9:18 a.m., with Administrator/Director of Nursing, when asked if there were QAPI documents for the year of 2018 she replied, "I do not have them." Surveyor requested for her to write a statement saying she did not have any QAPI documentation for the year 2018. She replied, "ok". Surveyor received the statement that Administrator/Director of Nursing typed, signed and dated 8/20/2021. In summary the agency did not follow the regulations or their own policy for QAPI. The Agency program was not evaluated, reviewed, and updated or revised at least twice within the calendar year, or more often if needed, by the governing board. There were no governing body meetings documented for 2018 and one meeting in 2019.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: This is a continuing deficiency previously cited on 04/25/18. Based on record review and interview, the agency's governing body failed to ensure the agency's Quality Assessment and Performance Improvement Program (QAPI) was reviewed and updated/revised twice within the calendar year of 2018. This failure could place the agency's patients at risk of receiving inadequate care and services due to the agency not being able to trend patterns in issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff, client complaints, the agency's response to complaints, competency of care and client incidents and occurrences and/or the agency response to incidents and occurrences. Findings included: Review of the agency policy titled, "Governing Body", with a revision date of 01/29/2020 included, " ...Responsibilities of the Governing Body to include: ... Assume overall responsibility for ensuring that the QAPI program reflected the complexity of the HHA and its performance across the spectrum of care, including the prevention and reduction of medical errors. Required not only to ensure that performance improvement efforts were prioritized, but that they were also evaluated for effectiveness. Required to define, implement, and maintain a program for quality improvement and patient safety that was ongoing and agency-wide ..." Review of the agency policy titled, "Quality Assessment Performance Improvement Plan", with a revision date of 01/29/2020, included, "The Agency will develop, implement and maintain an effective ongoing HHA-wide, data driven Quality Assessment Performance Improvement Plan (QAPI) program ... The Agency will maintain documentary evidence of the QAPI program and will be able to demonstrate the program operation to CMS ... The Agency's governing body is responsible for ensuring the following: 1. An on-going program for quality improvement and patient safety is defined, implemented and maintained 2. The Agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness ... 7. The governing board will assemble a QAPI working team that consists of the Administrator, supervising nurse or therapist, clinical coordinator and individuals representing the scope of services provided by the agency ... Program Procedure: ... The program will be evaluated, reviewed, and updated or revised at least twice within the calendar year, or more often if needed, by the governing board." At the Entrance conference on 08/18/21 at 11:59 a.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/18/21 at 5:35 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation be available the morning of 08/19/2021. At approximately 9:20 a.m. on 08/19/2021, with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation once again. In the afternoon on 08/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation for the fourth time. During an interview conducted on 8/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing when presented with the findings of if there was a QAPI manual/documentation she replied, " I guess you will just have to cite me because I do not have a QAPI manual because I have not done any QAPI." When asked if she had any QAPI activities that she could show. She said, "No. I have done some chart audit's, but I do not write anything down." When asked if she had done any QAPI at all since the last survey she replied, "No I have not. I had thought I would call a consultant to help me, but I have not done that either." The Surveyor requested a statement be written stating she did not have a QAPI program from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/19/21 at 5:00 p.m., with the Administrator/Director of Nursing, the Surveyor requested the statement for QAPI documentation be available the morning of 08/20/2021. During an interview conducted on 8/20/2021 at 9:05 a.m., with Administrator/Director of Nursing, when asked if she had the statement that was requested yesterday regarding the QAPI documentation from 08/20/2018 to 08/20/2021. She replied, "No I did not want to write it, so I stayed up all night putting this manual together." Surveyor reviewed the manual of QAPI documentation. Documentation was for years 2019, 2020 & currently 2021. It did contain the following: " Board of Directors minutes of meeting for Agency on February 19, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on April 15, 2020 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on February 27, 2021 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 11, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for January 4, 2020 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for January 4, 2020 with no signatures. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. " QAPI Committee minutes for January 14, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for July 10, 2020 with signatures of the Administrator & the alternate Administrator. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. " QAPI Committee minutes for July 15, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Tabletop & Annual Evaluation for Emergency Preparedness Plan for Covid 19 dated December 29, 2020 - no signatures. This should have been in the emergency preparedness manual. It discussed some Covid 19 issues. No QAPI mentioned in report. " QAPI Committee minutes for January 4, 2021 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 30, 2021 with no signatures. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation) & the four discharges that are mentioned on the report with their discharge dates are not on the discharge list provided to surveyor. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature typed in and not signed. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation). It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. During an interview conducted on 8/20/2021 at 9:18 a.m., with Administrator/Director of Nursing, when asked if there were QAPI documents for the year of 2018 she replied, "I do not have them." Surveyor requested for her to write a statement saying she did not have any QAPI documentation for the year 2018. She replied, "ok". Surveyor received the statement that Administrator/Director of Nursing typed, signed and dated 8/20/2021. In summary the governing body did not follow the regulation or their own policy for QAPI. The governing body did not assume responsibility for the agency QAPI program. The governing body did not assume the overall responsibility for ensuring the QAPI program reflected the complexity of the home health agency and its services, involves all services including those provided under contract or arrangement. They did not focus on indicators related to improving outcomes and take actions that addresses the home health agency's performance across the spectrum of care, including the prevention and reduction of medical errors. They did not ensure that performance improvement efforts were prioritized, but that they were also evaluated for effectiveness. They did not define, implement and maintain a program for quality improvement and patient safety that was ongoing and agency wide. They did not establish clear expectations for patient safety. They did not appropriately address any findings of fraud or waste in order to assure that resources are appropriately used for patient care activities and that patients are receiving the right care to meet their needs.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interviews, the Administrator failed to be responsible for all day-to-day operations of the agency, in that: 1) The Administrator failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed and immediately corrected identified problems that directly or could potentially threaten the patient care and safety, in that the Agency did not have or complete a Performance improvement Project from 8/20/2108 to 8/20/2021. 2) The Administrator failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal patient care outcomes from 8/20/2108 to 8/20/2021. 3) The Administrator failed to implement Performance improvement activities that track adverse patient events, analyze their causes, and implement preventative actions. The agency failed to implement a Performance improvement activity to ensure optimal patient outcomes from 8/20/2108 to 8/20/2021. 4) Based on record review and interview, the agency failed to implement Performance improvement activities that track adverse patient events, analyze their causes, and implement preventative actions. The agency failed to implement a Performance improvement activity to ensure optimal patient outcomes from 08/20/2018 to 08/20/2021. 5) The Administrator failed to ensure the agency's Quality Assessment and Performance Improvement Program was reviewed and updated/revised at least twice within the calendar from 08/20/2018 to 08/20/2021. Findings included: At the Entrance conference on 08/18/21 at 11:59 a.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation for from 08/20/2018 to 08/20/2021. Prior to leaving the Agency on 08/18/21 at 5:35 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation be available the morning of 08/19/2021. In the afternoon on 08/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing, the Surveyor requested the Agency's QAPI documentation for the fourth time. During an interview conducted on 8/19/2021 at 2:53 p.m., with the Administrator/Director of Nursing, when asked if there was a QAPI manual/documentation she replied, " I guess you will just have to cite me because I do not have a QAPI manual because I have not done any QAPI." When asked if she had any QAPI activities that she could show. She said, "No. I have done some chart audit's, but I do not write anything down." When asked if she had done any QAPI at all since the last survey she replied, "No I have not. I had thought I would call a consultant to help me, but I have not done that either." The Surveyor requested a statement be written stating she did not have a QAPI program for the years of 2018, 2019, 2020 and currently in 2021. During an interview on 8/19/2021 at 4:15 p.m., with Administrator/Director of Nursing, , when asked if she had Governing Body meetings with the minutes, she replied, "yes I have them." When asked who the governing body members are she stated herself (Administrator), Alt. Administrator and the outside interest person, Identifier H. Surveyor requested the Governing Body meeting minutes. She did bring one Governing Body meeting minutes dated December 22, 2020. Documentation did reveal they had requested the staff to sign up to get a Covid vaccine. Prior to leaving the Agency on 08/19/21 at 5:00 p.m., with the Administrator/Director of Nursing, the Surveyor requested the statement for QAPI documentation be available the morning of 08/20/2021. During an interview conducted on 8/20/2021 at 9:05 a.m., with Administrator/Director of Nursing, , when asked if she had the statement that was requested yesterday regarding the QAPI documentation for 2018, 2019, 2020 & currently for 2021. She replied, "No I did not want to write it, so I stayed up all night putting this manual together." Surveyor reviewed the manual of QAPI documentation. Documentation was for years 2019, 2020 & currently 2021. It did contain the following: " Board of Directors minutes of meeting for Agency on February 19, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on April 15, 2020 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Board of Directors minutes of meeting for Agency on February 27, 2021 with the signatures of the Administrator & the alternate Administrator. These minutes do not have the outside interest person's signature. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 11, 2019 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for January 4, 2020 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for January 4, 2020 with no signatures. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. " QAPI Committee minutes for January 14, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI / Utilization Review Report for July 10, 2020 with signatures of the Administrator & the alternate Administrator. It shows some OASIS percentages from IQES report. The form is not completed and has many blank areas. " QAPI Committee minutes for July 15, 2020 with signatures of the Administrator& the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Tabletop & Annual Evaluation for Emergency Preparedness Plan for Covid 19 dated December 29, 2020 - no signatures. This should have been in the emergency preparedness manual. It discussed some Covid 19 issues. No QAPI mentioned in report. " QAPI Committee minutes for January 4, 2021 with signatures of the Administrator & the alternate Administrator. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " QAPI Committee minutes for July 30, 2021 with no signatures. These minutes do not contain any other people (therapist or nurse or attendant) present. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation) & the four discharges that are mentioned on the report with their discharge dates are not on the discharge list provided to surveyor. It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. " Clinical Record Review with no date evident. Did have the Administrator signature typed in and not signed. However, it has in some sections of check off portions that mention CHAP (this agency has never had accreditation). It does not contain any measurable, analyzed or tracked quality indicators to assess care services and operations of the agency. Surveyor noted on 08/20/2021 the documents presented in the QAPI manual today did not contain any therapist signatures on any of the presented documents. During an interview conducted on 08/20/20 at 8:50 a.m., with Administrator/Director of Nursing, asked if therapy attended the QAPI meetings she replied, "No they haven't." During an interview conducted on 8/20/2021 at 9:18 a.m., with Administrator/Director of Nursing, when asked if there was QAPI documents for the year of 2018 she replied, "I do not have them.". Review of the agency policy titled, "Responsibilities of the Administrator", with a revision date of 01/29/2020, included, " The administrator will be responsible for all day to day operations of a Home Health Agency and for implementing and supervising the administrative policies and operations of the Agency and for supervising the provision of all services to agency clients on a day to day basis. An Administrator will be responsible but not limited to the following: " Manage the daily operations of the agency: " Organize and direct the agency's ongoing functions; " Administratively supervise the provision of quality care to patients; " Ensure implementation of agency policies and procedures and development of personnel qualifications through supervision; " Ensure the documentation of services provided is accurate and timely; Review of the agency policy titled, "Organization and Administration of Services", with a revision date of 01/29/2020, included, "The Home Health Agency must assure that administrative and supervisory functions are not delegated to another agency or organization and all services not furnished directly are monitored and controlled. (b) Administrator The administrator must: " Be responsible for all day to day operations of the HHA