Every finding on record at Integrity Home Health Care Services, LLC

Emergency Preparedness: The facility must meet all applicable Federal, State, and local emergency preparedness requirements as outlined in the Medicare and Medicaid Programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. This is a Recertification Survey for Medicare and was surveyed on May 7, 2024, through May 9, 2024. The following deficiencies were cited during the Medicare Recertification conducted May 7, 2024, through May 9, 2024.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review and staff interview it was determined the home health agency failed to implement and document Individual plans for each patient and include as part of the comprehensive patient assessment and document that these discussions occurred and also keep a copy of the individualized emergency plan in the patient's file as well as provide a copy to the patient and or their caregiver. This deficient practice has the potential that patients and their caregivers would not be prepared in the event of an emergency posing the risk of negative patient outcomes. Findings include: A review of Integrity Home Health Care Services Policy C-140, titled, "Client Admission Process", revealed, "...Admission criteria are standards by which a client can be deemed appropriate for admission. These standards include...10.The admission professional will...l. Develop an Emergency Plan with the client/caregiver....". A review of Integrity Home Health Care Services Policy C-655, titled, "Emergency Care", revealed, "...Each client admitted to the agency will be asked to develop and authorize an emergency plan the agency staff can implement...2.The Admitting professional shall discuss emergency care with the clients, and complete the Authorization for Emergency Preparedness Plan...6. The original Authorization for Emergency Procedure Plan shall be retained in the clinical record....". A review of a document titled " Integrity Home Health Care Services Emergency Preparedness Plan", revealed, "... Patient Emergency Preparedness Plan...Family Emergency Preparedness Plan....". A review of 10 patient medical records revealed that ten(10) of ten(10) patient records had no evidence of an Emergency Preparedness Plan in the clinical record(s). A request was made for additional documentation for the required individualized emergency plans. No additional documentation could be provided. In an interview with Employee #1, he/she acknowledged that no Emergency Preparedness Plans were present in the medical records for the 10 aforementioned patients. No additional information could be provided.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and document review it was determined that the Hone Health agency failed to develop an Emergency Preparedness communication plan for sharing information. This deficiency has the potential to put patients and families at risk for follow up care needed in the time of an emergency. Findings include: A review of the Emergency Preparedness plan "Emergency Management Policy", B-400, item #7- "Clients and staff should use local radio station to listen for updates.." When asked during an interview on May 8, 2024 for direction on which radio station is listed for emergency information updates, Employee #1 confirmed that no specific information was present.

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 review of facility documentation and interview on May 8, 2024, it was determined that the facility has failed to participate in a community full scale exercise or a comprehensive table top emergency preparedness drill in the past calendar year. This deficiency poses a risk to staff and patient welfare in the event of an emergency event, as gaps in procedure, patient care and preparedness are not being updated. Findings include: A review of the "Emergency Preparedness Policy" B-400 for the facility failed to include documentation of a community full scale exercise or comprehensive table top participation in the last 12 calendar months. Interview with Employee #1 on May 8, 2024 confirmed that the facility had not participated in either a community full scale exercise or a comprehensive table top exercise in the previous 12 calendar months.

Deficiencies were cited at the time of the Medicare Recertification survey conducted on May 7, 2024, through May 9, 2024. Four(4) home visits were conducted. Emergency Preparedness Appendix Z was conducted in conjunction with the Recertification.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and staff interviews it was determined the HHA failed to advise patients and patient representatives of the names, addresses, and telephone numbers of the required federally and state-funded entities. This deficient practice has the potential that patients are not being adequately informed and educated on resources posing the risk of negative outcomes and patient rights violations. Findings include: A review of Integrity Home Health Care Services policies and procedures were reviewed and no policy was present to address the required Federally and State funded entities. A request was made for additional policies, none were received. A review of the Integrity Home Health Care Services admission folder revealed a document titled, "PHONE NUMBERS & EMERGENCY INSTRUCTIONS", revealed, "...IN CASE OF EMERGENCY 911...INTEGRITY HOME HEALTH CARE SERVICES...ARIZONA DEPARTMENT OF HEALTH SERVICES...ARIZONA DEPARTMENT OF HEALTH SERVICES HOME HEALTH HOTLINE...D.E.S. ADULT PROTECTIVE SERVICES...AZ AGENCY CENTER ON AGING/SENIOR HELP LINE...ARIZONA CENTER FOR DISABILITY LAW...GOVERNOR'S OFFICE FOR AMERICAN'S WITH DISABILITY...INFORMATION ON ADVANCE DIRECTIVES DOROTHY GARSKE CENTER... RED CROSS...MARICOPA COUNTY EMERGENCY MANAGEMENT...PUBLIC HEALTH DEPARTMENT....". No addresses for the mentioned agencies were located in the document. In an interview conducted on March 28, 2024, with Employee #1, he/she confirmed that the required agencies were not listed in the patient admission folder. No additional information could be provided. No additional documentation could be provided.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on record review, observation, and staff interview it was determined the home health agency failed to provide Information must be provided to patients in plain language and in a manner that is accessible and timely to persons with disabilities, including accessible websites and the provision of auxiliary aids and services at no cost to the individual following the Americans with Disabilities Act and Section 504 of the Rehabilitation Act and Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This deficient practice has the potential that patients are not allowed to participate in the development of their plan of care posing the risk for patient and Civil Rights violations. Findings include: A review of Integrity Home Health Care Services Policy C-400, titled, "CLIENT/FAMILY EDUCATION", revealed, "...Planning and providing for educational needs of clients and allocation the resources necessary to meet these needs...To provide education and information in a format easily understood and in consideration of cultural and personal preferences...f. Information presented in the appropriate language(written/verbal) as necessary to assure teaching goals are met....". A review of Integrity Home Health Care Services Policy C-860, titled, "COMMUNICATION WITH LIMITED-ENGLISH-PROFICIENCY PERSONS", revealed, "...Agency shall provide for communication with limited-English-proficient persons...We will contact TeleInterpreters at (800) 811-7881. When required, this service will be provided at no extra cost to the patient..... Family members or friends of clients may be used as translators only if the client requests them, and after the agency has offered to provide a translator....The offer to provide a translator and client response shall be documented on the Deaf or Hearing-Impaired Client Information Sheet and retained in the clinical record....". A phone call was placed to TeleInterpreters, (800) 811-7881. The phone number was no longer in service. A request was made for the contract for TeleInterprerters, one could not be provided. A review of the Integrity Home Health Care Services admission folder revealed no information on how a patient or the patient caregiver shall have free access to language, auxiliary aides, and services. Observation during a home visit made on 05/08/2024 revealed the patient did not read or speak English. Family was relied upon to interpret between the clinician and the patient. A review of Patient #9's medical record revealed that the patient primary language preference was English. Further review of the medical record revealed the patient was Arabic. No evidence was documented in the medical record that access to a free language interpreter/assistance was made. In an interview conducted on 05/08/2024, with Employee #1, he/she stated that the Home Health Agency(HHA) has a contract with LanguageLine. A request was made for the contract with LanguageLine. One could not be produced. Employee #1 presented an Electronic Mail(E-Mail) dated 10/10/2016 that was provided in place of an executed contract. Employee #1 stated customer service was unable to provide one as the system was down. There was no information that TTY services were available for sensory-impaired clients using the updated LanguageLine information provided in the email.

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 staff interviews it was determined the HHA failed to HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. This deficient practice has the potential that issues regarding patient care, agency needs, and infections are not being identified, addressed, and corrected posing the risk for negative outcomes. Findings include: A white binder was presented labeled "QM". A document titled, "INTEGRITY HOME HEALTH CARE QM 2023", revealed "Infection Control...WOUNDS...UTI...OTHER...ANTIBIOTICS...INCIDENT REPORTS...INSERVICES...STAFF REQUIREMENTS...FINANCIALS...CAHPS....". A white binder was presented labeled Performance Improvement Project(PIP). There was no evidence of PIPs being completed since 2019. Additional documentation was asked for and not received. A review of Integrity Home Health Care Services Policy B-100, titled, "Governing Body", revealed, "...Appoint the Professional Advisory Board(Quality Control) as required by State licensure and/or Medicare Conditions of Participation to guide the organization in the formulation and review of policies and procedures to ensure the highest quality of care....". A review of Integrity Home Health Care Services Policy B-160, titled, "PROFESSIONAL ADVISORY BOARD", revealed, "...The Professional Advisory Board shall review the findings of the quarterly...Performance Improvement activities....". Integrity Home Health Care Services Policy B-200, titled, "ORIENTATION GUIDELINES FOR ADVISORY BOARD ADN GOVERNING BODY MEMBERS", revealed, "... Planning Function: c. Quality improvement measures..,,". A review of the Governing Board Meeting dated, May 25, 2022, revealed no documentation of QAPI being reported or reviewed. A review of the Governing Board Meeting dated April 5, 2023, revealed no documentation of QAPI being reported or reviewed. A review of Professional Advisory Board Committee meeting minutes and agenda dated, May 25, 2022, revealed no documentation of QAPI being discussed, reviewed, or a report presented. A review of Professional Advisory Board Committee meeting minutes and agenda dated, April 5, 2023, revealed no documentation of QAPI being discussed, reviewed, or a report presented. In an interview conducted on May 9, 2024, with Employee #1, he/she confirmed that there was no evidence that a QAPI program report was discussed or reviewed in the documentation presented in the aforementioned binders or meeting minutes. He/she also confirmed that no PIP's have been made or documented since 2019. In an interview with Employee #2, he/she confirmed that no evidence of a continuing QAPI program and PIP's were present in the aforementioned presented material and no additional information could be provided or was available.

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 staff interview it was determined the home health agency failed to develop and conduct performance improvement projects. this deficient practice has the potential that patient care agency needs are not being identified addressed and corrected posing the risk for negative outcomes. Findings include A review of Integrity Home Health Care Services Policy B-150 titled "Professional Advisory Board" revealed, "...The Professional Advisory Board shall review the findings of the quarterly clinical record review and other Performance improvement activities....". A review of the "Performance Improvement Program" binder revealed most recent documents provided are titled "... Integrity Home Health Care Services QM2019...." In an interview conducted on May 9, 2024, with employee # 1, he/she confirmed that no performance improvement project(s) have been conducted or created since 2019. No additional documentation could be provided. In an interview conducted on May 9, 2024, with employee # 2, he/she confirmed that no performance improvement project(s) have been conducted or created since 2019. No additional documentation could be provided.

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: Findings include: A review of Integrity Home Health Care Services Policy B-100, titled, "Governing Body", revealed, "...Appoint the Professional Advisory Board(Quality Control) as required by State licensure and/or Medicare Conditions of Participation to guide the organization in the formulation and review of policies and procedures to ensure the highest quality of care....". A review of Integrity Home Health Care Services Policy B-160, titled, "PROFESSIONAL ADVISORY BOARD", revealed, "...The Professional Advisory Board shall review the findings of the quarterly...Performance Improvement activities....". Integrity Home Health Care Services Policy B-200, titled, "ORIENTATION GUIDELINES FOR ADVISORY BOARD ADN GOVERNING BODY MEMBERS", revealed, "... Planning Function: c. Quality improvement measures..,,". A review of the Governing Board Meeting dated, May 25, 2022, revealed no documentation of QAPI being reported or reviewed. A review of the Governing Board Meeting dated April 5, 2023, revealed no documentation of QAPI being reported or reviewed. A review of Professional Advisory Board Committee meeting minutes and agenda dated, May 25, 2022, revealed no documentation of QAPI being discussed, reviewed, or a report presented. A review of Professional Advisory Board Committee meeting minutes and agenda dated, April 5, 2023, revealed no documentation of QAPI being discussed, reviewed, or a report presented. In an interview conducted on May 9, 2024, with Employee #1, he/she confirmed no evidence that a QAPI program report was discussed or reviewed in the documentation presented in the aforementioned binders or meeting minutes. In an interview with Employee #2, he/she confirmed no evidence of a continuing and ongoing QAPI program. He/she further confirmed that no additional documentation could be provided.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and staff interviews it was determined the HHA failed to include all skilled professional staff to provide input into and participate in the HHA's QAPI program. This deficient practice poses the risk that issues regarding patient care, and patient services would not be identified, addressed, and corrected posing the risk for negative and poor patient outcomes. Findings include: A white binder was presented labeled "QM". A document titled, "INTEGRITY HOME HEALTH CARE QM 2023", revealed "Infection Control...WOUNDS...UTI...OTHER...ANTIBIOTICS...INCIDENT REPORTS...INSERVICES...STAFF REQUIREMENTS...FINANCIALS...CAHPS....". A white binder was presented labeled Performance Improvement Project(PIP). There was no evidence of PIPs being completed since 2019. Additional documentation was asked for and not received. A review of Integrity Home Health Care Services Policy B-100, titled, "Governing Body", revealed, "...Appoint the Professional Advisory Board(Quality Control) as required by State licensure and/or Medicare Conditions of Participation to guide the organization in the formulation and review of policies and procedures to ensure the highest quality of care....". A review of Integrity Home Health Care Services Policy B-160, titled, "PROFESSIONAL ADVISORY BOARD", revealed, "...The Professional Advisory Board shall review the findings of the quarterly...Performance Improvement activities....". Integrity Home Health Care Services Policy B-200, titled, "ORIENTATION GUIDELINES FOR ADVISORY BOARD ADN GOVERNING BODY MEMBERS", revealed, "... Planning Function: c. Quality improvement measures..,,". A review of the Governing Board Meeting dated, May 25, 2022, revealed no documentation of QAPI being reported or reviewed. A review of the Governing Board Meeting dated April 5, 2023, revealed no documentation of QAPI being reported or reviewed. A review of Professional Advisory Board Committee meeting minutes and agenda dated, May 25, 2022, revealed no documentation of QAPI being discussed, reviewed, or a report presented. A review of Professional Advisory Board Committee meeting minutes and agenda dated, April 5, 2023, revealed no documentation of QAPI being discussed, reviewed, or a report presented. No documentation that all skilled professional staff has been providing input at any time since 2017 to the QAPI program. Additional documentation was asked for an not received. In an interview conducted on May 9, 2024, with Employee #1, he/she confirmed that there was no evidence that a QAPI program report was discussed or reviewed in the documentation presented in the aforementioned binders or meeting minutes. He/she also confirmed that no PIP's have been made or documented since 2019. No additional documentation could be provided. In an interview with Employee #2, he/she confirmed that no evidence of a continuing QAPI program and PIP's were present in the aforementioned presented material and no additional information could be provided or was available.