Every finding on record at Faith Home Health Inc

During the recertification survey conducted on July 1-2, 2024 at Bayshore Home Health, a home health agency, Emergency Preparedness was reviewed. Bayshore Home Health is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was conducted at Bayshore Home Health on July 1-2, 2024. The facility was not in compliance with (CFR) 42, Part 484, Conditions of Participation Requirements for Home Health Agencies. The following conditions were out of compliance: §484.65 Condition: Quality Assessment/Performance Improvement

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 interviews, the agency failed to implement a QAPI program to plan agency initiatives, implement the initiatives, and monitor the effectiveness of the initiatives for the home care agency. (Refer to G656) Based on staff interview, the agency failed to develop, implement, evaluate, and maintain an effective Quality Assurance and Performance Improvement program (QAPI). (Refer to G660)

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on interviews, the agency failed to implement a QAPI program to plan agency initiatives, implement the initiatives, and monitor the effectiveness of the initiatives for the home care agency. The findings included: An interview with the administrator was conducted on 7/02/2024 at 10:00 AM. The administrator said they had not started a QAPI program yet because they had not admitted any patients.

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 staff interview, the agency failed to develop, implement, evaluate, and maintain an effective Quality Assurance and Performance Improvement program (QAPI). The findings included: An interview with the administrator was conducted on 7/02/2024 at 10:00 AM. The administrator said they had not started a QAPI program yet because they had not admitted any patients.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interviews and record reviews, the agency failed to provide skilled professional services to skilled patients for the home health agency. The findings included: An Interview with the Administrator was conducted on 7/01/2024 at 9:35 a.m. The Administrator stated that the agency has not admitted any skilled home health patients since the change in ownership. "We are not currently admitting any patients yet. Our census is 0. I cannot give you a report of the unduplicated census because we have not yet admitted any patient for services." A letter from the accrediting body dated 6/01/2023, written by the Senior Program Director, stated, "The home care agency has been approved for Accreditation for home health services. The Accreditation is awarded for a period of one year, effective May 18, 2023, through May 17, 2024. A review of agency reports from May 2023 to the present revealed no completed Outcome and Assessment Information Set (OASIS) assessments or evidence that skilled care was provided by the agency.