Every finding on record at Maritona Health Services Inc

A Recertification Survey entrance conference was conducted on 07/05/23 with the Administrator, Alternate Administrator and Office manager at 10:07 AM. Census Licensed & Certified Home Health Services:12 Licensed Home Health Services: 0 Personal Assistance Services: 1 An exit conference was conducted on 07/06/2023 with Administrator, Alternate Administrator, and Office Manager at 12:29 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.

A Recertification Survey entrance conference was conducted on 07/05/23 with the Administrator, Alternate Administrator and Office manager at 10:07 AM. Census Licensed & Certified Home Health Services:12 Licensed Home Health Services: 0 Personal Assistance Services: 1 An exit conference was conducted on 07/06/2023 with Administrator, Alternate Administrator, and Office Manager at 12:29 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.

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 have at least one performance improvement project in development, on-going, or completed each year for 2 of 3 years reviewed (2021, 2022) and 2020. The failure places the patients at risk of receiving inadequate care that could have been corrected with an improvement project. During an interview with the agency administrator, alternate administrator, and office manager occurred on 07/05/2023 at 10:51 AM. Agency administrator, alternate administrator, and office manager were asked if they conducted performance improvement projects. Agency administrator asked for examples of performance projects. The administrator responded “no that they do not have any.” The agency administrator returned later with a binder of a 2020 performance improvement project titled,” Performance Improvement Project (PIP),” dated 01/08/2020. No additional notes, findings, or developments had been added to the document since January, 2020. When the administrator was asked if they continue to add to this performance improvement project, the administrator replied “no.” The administrator was asked if any other performance improvement projects had been initiated, he responded “no.” Record review of the policy titled “Quality Assurance Performance Improvement Program,” dated 01/13/2018, stated that the Home Health Agency will conduct performance improvement projects annually and that documentation of projects undertaken will occur along with measurable progress achieved in the projects.