Every finding on record at Dls Rehab Services, Inc.

A recertification survey was conducted on 07/11/2024 at noon. The census was 12 Licensed and Certified patients. An exit conference was conducted on 07/16/2024 at 1:49 PM. The agency was in compliance with the Conditions of Participation for Emergency Preparedness for Home health agencies.

A Recertification survey was conducted on 07/11/2024 at noon. The census was 12 Licensed and Certified patients. An exit conference was conducted on 07/16/2024 at 1:49 PM. Abbreviations: DON – Director of Nurses QAPI – Quality Assurance 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 conduct performance improvement projects for 2 (2022, 2023, and through first quarter of 2024) of 2 years of QAPI records reviewed. This failure meant the patients were subjected to potential harm and poor-quality care when the agency failed it identify and conduct performance improvement activities. During the entrance conference on July 11, 2024, at noon, the surveyor requested the agencies’ QAPI documents. On July 16, 2024, the surveyor reviewed the QAPI documents provided for 2022, 2023, and through first quarter of 2024. The documents provided had a quarterly report form which documented Indicators and Findings / Follow-up/Outcomes/ Action to Prevent Reoccurrence. The quarterly report forms had an area titled: Quality Indicators which was left blank, and an area titled: Performance Improvement Project Status which documented “NA.” Review of all the quarterly reports and documents provided found no evidence or documentation of any Performance Improvement Projects for 2022, 2023 and through the first Quarter of 2024. An interview was conducted with the Administrator and the DON on July 16 at approximately 1PM. The surveyor reviewed the findings of the review of the QAPI documents provided and asked about the Performance Improvement Projects. The DON stated they did the QAPI and was not aware of the Performance Improvement Projects requirements. The DON and Administrator stated they would conduct the quality assurance tasks required. Agency policy titled: “Quality Assessment Performance Improvement Program QAPI.5” last reviewed 050124 read in part: “Performance Improvement projects – 1. The number and scope of distinct projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…”