Every finding on record at Exodus Healthcare Services Inc

Purpose of visit: Recert/Relicensure Survey Entrance: 05/16/2023 at 9:54 AM with the Administrator/Director of Nursing. Agency Census: 0 Licensed and Certified Home Health Services (L&CHHS)-0 Licensed Home Health Services (LHHS)- 0 Personal Assistance Services (PAS) -0 Exit Conference was conducted on 05/18/2023 with the Administrator/Director of Nursing at 11:30 AM. 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: Emergency Preparedness Plan (EPP) DFW (Dallas Forth Worth) Quality Assessment Performance Improvement Plan (QAPI) Plan of Care (POC) Hypertension (High blood pressure) is a common condition that affects the body's arteries. It's also called hypertension. If you have high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart must work harder to pump blood. Heart Failure -Heart failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with all Federal and State emergency preparedness requirements, in that: The agency did not conduct an annual review of their emergency preparedness plan (EPP) for the years 2020, 2021, and 2022. This failure placed the agency patients at risk of harm in the event of an emergency or disaster if the agency's emergency plan was not effective. Findings included: Record review of the EPP documents provided by the agency revealed there were no records to confirm that a review and update of the EPP for the years 2020, 2021, and 2022. During an interview on 05/17/23 at approximately 10:41 a.m. with the Administrator/ Director of Nursing, the Surveyor presented the above findings. The surveyor asked who the Disaster Coordinator was for the agency. The Administrator/Director of Nursing stated, "I am the disaster coordinator." The Administrator/Director of Nursing confirmed the EPP update was not completed for the years 2020, 2021, and 2023. The Administrator/Director of Nursing stated, “I don’t know why it wasn’t done. I can’t tell you why it wasn’t done.” Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" revised 080108 read in part: "... POLICY .... Agency will involve the administrator, supervising nurse, and other agency leaders as appropriate in the development, implementation, and evaluation of the emergency preparedness and response plan. The effectiveness of the Emergency Preparedness Plan will be evaluated at least annually and after each actual emergency response and will be included in the Agency’s Annual program evaluation.”

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to test the response phase of its emergency preparedness and response plan in a planned drill or during an actual emergency in three (2020, 2021 and 2022) of three years reviewed. This failure has the potential to place the agency patients at risk of harm in the event the agency lacked the organized preparation and planning for care and services in the event of a disaster. Findings included: A review of the emergency preparedness plan binder, policies and procedures revealed the following: Review of the website for the Office of the Texas Governor revealed that on March 13, 2020, the Governor for the State of Texas declared a state of disaster in Texas due to Novel Coronavirus Disease of 2019. Review of the contents in the agency's "Emergency Preparedness" binder reflected no evidence the agency tested their response phase of its emergency preparedness and response plan that affected the agency's service area, for the pandemic on March 13, 2020. No evidence of any records to establish the agency conducted an internal review after the Winter Storm Uri that occurred on 02/11/2021, the North Texas snowstorm that occurred 02/03/2022, and the EF-6 tornado on 5/14/2021in the DFW (Dallas Forth Worth) area. There were no other reports in the binder that indicated that the agency had conducted full-scale community based, full-scale facility-based or table-top exercises or an actual emergency, to test the emergency plan at least annually, for the years 2020, 2021, and 2022. During an interview on 05/17/22 at 10:41 a.m. with the Administrator/ Director of Nursing, the Surveyor presented the above findings. The surveyor asked who the Disaster Coordinator was for the agency. The Administrator/Director stated, "I am the disaster coordinator." The Administrator/Director of nurses confirmed the EPP binder did not contain any drills for the years 2020, 2021, 2022 and no internal reviews after the for the pandemic on March 13, 2020, the Winter Storm Uri that occurred on 02/11/2021, the North Texas snowstorm that occurred 02/03/2022, and the EF-6 tornado on 5/14/2021, in the DFW (Dallas Forth Worth) area. The Administrator/Director of Nursing stated, “I can’t tell you why it wasn’t done.” Agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" revised 080108 read in part: " POLICY... The effectiveness of the Emergency Preparedness Plan and Response will be evaluated at least annually and after each actual emergency response and will include the Agency’s Annual program evaluation…PROCEDURE…The Administrator, or designee, will initiate and discontinue the implementation of the Emergency Preparedness and Response Plan…Disaster Coordinator or designee will be responsible for documenting all aspects of the disaster.”

Purpose of visit: Recert/Relicensure Survey Entrance: 05/16/2023 at 9:54 AM with the Administrator/Director of Nursing. Agency Census: 0 Licensed and Certified Home Health Services (L&CHHS)-0 Licensed Home Health Services (LHHS)- 0 Personal Assistance Services (PAS) -0 Exit Conference was conducted on 05/18/2023 with the Administrator/Director of Nursing at 11:30 AM. 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: Emergency Preparedness Plan (EPP) DFW (Dallas Forth Worth) Quality Assessment Performance Improvement Plan (QAPI) Plan of Care (POC) Hypertension (High blood pressure) is a common condition that affects the body's arteries. It's also called hypertension. If you have high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart must work harder to pump blood. Heart Failure -Heart failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to enforce its policy to develop a plan of care for 6 (Patients #1, #2, #3, #5, #6 and #7) of 7 agency discharged patients that received skilled nursing care and whose records were reviewed. This failure placed the patients at potential risk of harm of not receiving care, services and interventions at the appropriate time for the patient's specific needs. Findings included: Review of discharged Patient #1’s clinical record for the certification period of 05/24/21 to 07/22/21 revealed the following: Patient #1’s clinical record revealed a Plan of Care for the current certification period 07/28/20 to 09/25/20. The Plan of care revealed a start of care date 01/30/20, with a primary diagnosis of Essential (primary) Hypertension (high blood pressure), signed and dated 07/24/20 by the Director of Nursing. The record did not include evidence of any other POC dated after 09/25/20. Review of discharged Patient #2’s clinical record for the certification period of 11/22/21 to 01/20/21 revealed the following: Patient #2’s clinical record revealed a Plan of Care for the current certification period 03/06/20 to 05/04/20. The Plan of care revealed a start of care date 08/05/14, with a primary diagnosis of Essential (primary) Hypertension, signed and dated 01/03/30 by the Director of Nursing. The record did not include evidence of any other POC dated after 05/04/20. Review of discharged Patient #3’s clinical record for the certification period of 12/10/21 to 02/07/22 revealed the following: Patient #3’s clinical record revealed a Start of Care signed and dated by the 12/10/2021 by the Director of Nursing. The record did not contain evidence of a plan of care for the certification period of 12/10/21 to 02/07/22. The record contained a Plan of Care for the certification period 08/04/21 to 10/02/21. The Plan of care revealed a start of care date 02/11/20, with a primary diagnosis of Essential (primary) Hypertension, signed and dated 08/04/21 by the Director of Nursing. The record did not include evidence of any other POC dated after 08/04/21. Review of discharged Patient #5’s clinical record for the certification period of 03/05/21 to 05/03/21 revealed the following: Patient #5’s clinical record revealed a Plan of Care for the current certification period 09/06/20 to 11/04/20. The Plan of care revealed a start of care date 06/15/13, with a primary diagnosis of Urinary tract infection site not specified, signed and dated 07/03/20 by the Director of Nursing. The record did not include evidence of any other POC dated after 11/04/20. Review of discharged Patient #6’s clinical record for the certification period of 01/02/21 to 03/02/21 revealed the following: Patient #6’s clinical record revealed a Plan of Care for the current certification period 08/05/20 to 10/03/20. The Plan of care revealed a start of care date 02/07/20, with a primary diagnosis of Essential (primary) Hypertension, signed and dated 08/04/20 by the Director of Nursing. The record did not include evidence of any other POC dated after 10/30/20. Review of discharged Patient #7’s clinical record for the certification period of 04/20/21 to 06/18/21 revealed the following: Patient #7’s clinical record revealed a Plan of Care for the current certification period 08/23/20 to 10/21/20. The Plan of care revealed a start of care date 02/25/20, with a primary diagnosis of Hypertensive (high blood pressure) heart disease with heart failure, signed and dated 08/23/20 by the Director of Nursing. The record did not include evidence of any other POC dated after 10/21/20. During an interview on 05/17/23 at 12:13 p.m. with the Administrator/Director of nursing, the Surveyor presented the above findings. The surveyor asked for the plan of cares for Clients #1, #2, #3, #5, #6 and #7. The Administrator/Director of nursing stated “I don’t have any plan of cares. I looked also but couldn’t find any the software company must have taken them out since I wasn’t able to pay for the services.” The surveyor asked if the agency uploaded the plan of cares signed by the physician into the electronic medical records. The Administrator/Director of nursing stated “No.” The surveyor asked for a copy of the signed plan of cares for patients #1, #2, #3, #5, #6 and #7. The Administrator/Director of nursing stated, “I don’t have any signed plan of cares.” Agency policy, dated 04/17/06, read in part, "PLAN OF CARE TX. 6, PURPOSE: To ensure that care provided is appropriately planned in a timely manner to meet the patient's specific needs and problems. Orders will be returned signed within 60 days or prior to billing for the final claim of an episode. POLICY: Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient's problems and/or needs. The Plan of Care will be signed and dated by a physician at certification and recertification... PROCEDURE: ... 5. The care plan is reviewed and/or revised, with physician participation, at least every 60 days...."

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 ensure the agency maintained a QAPI Program for 3 of 3 years (2020, 2021 and 2022) in that: 1) The QAPI program was not evaluated annually for its hospice-wide effectiveness on the quality of care provided and activities that impact upon patient health and safety for 2020, 2021 and 2022. 2) The QAPI Committee did not meet regularly to maintain an effective, ongoing, agency-wide data driven QAPI plan for 2020, 2021 and 2022. The failure could cause the agency to not monitor the effectiveness and safety of agency services provided to the agency's patients. The failure could also cause the agency to be unable to identify problems, implement corrective actions to ensure the health and safety of the agency's patients, and if necessary, revise policies. FINDINGS INCLUDED: QAPI binder review: 1. The binder did not contain an annual evaluation of the QAPI program for 2020, 2021 and 2022. 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 2020, 2021 and 2022. 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 05/17/2023 at 11:05 a.m., with the Administrator/Director of Nursing, the surveyor discussed the above findings. The Administrator/Director of Nursing said, "I forgot to do the QAPI.” Agency Policy titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROGRAM QAPI.1" dated of 010207, read in part, " .... POLICY ... Agency leaders will choose an approach to performance improvement that is planned systemic, Agency -wide in scope, collaborative in effort and includes all departments/disciplines…The QAPI Committee will meet at least quarterly or more if needed…The program will be evaluated, reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee.”

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 interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects for 3 of 3 (2020, 2021 and 2022) years reviewed. This failure in the hospice failing to develop, implement, and evaluate performance improvement projects for the years 2020,2021 and 2022 required and could have resulted in the hospice failing to identify and address areas of the hospice's program for which performance could be improved. The findings included: Review of the documentation regarding the hospice's QAPI Program included no documentation to indicate the hospice had developed, implemented, or evaluated a performance improvement project for the years of 2020, 2021 and 2022. During an interview on 05/17/23 at 11:10 a.m., with the Administrator/Director of Nursing the surveyor discussed the above findings. The Administrator/Director of Nursing said, "I didn’t know we were supposed to do a project."

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 leaders failed to ensure the agency maintained a QAPI Program for 3 of 3 years (2020, 2021 and 2022) in that: 1) The QAPI program was not evaluated annually for its agency-wide effectiveness on the quality of care provided and activities that impact upon patient health and safety for 2020, 2021 and 2022. 2) The QAPI Committee did not meet regularly to maintain an effective, ongoing, agency-wide data driven QAPI plan for 2020, 2021 and 2022. The failure could cause the agency to not monitor the effectiveness and safety of agency services provided to the agency's patients. The failure could also cause the agency to be unable to identify problems, implement corrective actions to ensure the health and safety of the agency's patients, and if necessary, revise policies. FINDINGS INCLUDED: QAPI binder review: 1. The binder did not contain an annual evaluation of the QAPI program for 2020, 2021 and 2022. 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 2020, 2021 and 2022. 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 05/17/2023 at 11:05 a.m., with the Administrator/Director of Nursing, the surveyor discussed the above findings. The Administrator/Director of Nursing said, "I forgot to do the QAPI.” Agency Policy titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROGRAM QAPI.1" dated of 010207, read in part, " .... POLICY ... Agency leaders will choose an approach to performance improvement that is planned systemic, Agency -wide in scope, collaborative in effort and includes all departments/disciplines…The QAPI Committee will meet at least quarterly or more if needed…The program will be evaluated, reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee.”