Every finding on record at Monarch Healthcare Inc

An Emergency Preparedness Recertification survey was initiated with the Administrator on 06.06.2023 at 2:10 PM. Census: Licensed and Certified- 0 Licensed Home Health- 24 Personal Assistance Services- 33 The agency was in substantial compliance with 42 CFR Part 484.102 Emergency Preparedness requirements for Home Health.

A Recertification survey was initiated with the Administrator on 06.06.2023 at 2:10 PM. Census: Licensed and Certified- 0 Licensed Home Health- 24 Personal Assistance Services- 33 Acronyms used: QAPI- Quality Assurance Performance Improvement PIP- Performance Improvement Project COVID- Coronavirus disease

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 maintain a Quality Improvement / Performance Improvement Program to measure, analyze, and track quality indicators, including a representative sample of services furnished in both active and discharged records, a determination that services have been performed as outlined in the individualized services, and other aspects of performance that would enable the agency to assess outcomes that are measurable and have a written plan of implementation for three of the three-year period of review (06/06/2020 to 06/06/2023). This failure caused the agency to have no effective mechanism to monitor, evaluate and improve the care and services to the agency patients. FINDINGS: The surveyor requested the QAPI program documents during the entrance conference on 06/06/2023. A review of documents provided by the Administrator on 06/14/2023 at 1:50 PM revealed: Patient Satisfaction surveys; Infection control logs and Professional Advisory Committee meetings dated: 01/10/21; 01/15/22 and 01/11/2023. There was no evidence of completed QAPI activities for 2020, 2021, and 2022. There were no samples of auditing services furnished to patients in active and discharged charts. In an interview with the Administrator on 06/20/23 at approximately 1:00 PM, the surveyor reviewed the findings and asked about the agency’s lack of QAPI activities. The Administrator stated, “since COVID, we have not had anything done, the consultant has not been here (in the agency).” Agency policy, quoted in part, dated 10.01.16, “QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN, QAPI.1, PURPOSE: To develop a Quality Assessment Performance Improvement (QAPI) Plan, implemented by the QAPI Committee, that captures significant outcomes that are essential to optimal care and are used in the care planning and coordination of services and events. POLICY: 1. The Agency will develop a plan that is evaluated, reviewed and updated or revised at least once within the calendar year, or more often in needed… II. The Agency will strive to improve operational and patient/client/health outcomes by implementing a performance improvement plan that incorporates the following essential processes: … B. Monitoring performance through data collection, C. Analyzing current performance, and D. Improving and sustaining improved performance over time….”

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: THIS IS A CONTINUING VIOLATION, CITED FROM THE SURVEY CONDUCTED 09.11.2020. Based on record review and interview, the agency failed to conduct performance improvement projects annually for three of the three-year period of review (06/06/2020 to 06/06/2023). This failure potentially subjected patients to substandard care when the agency had not evaluated the care and operations and developed plans to improve performance, and or address any issues that were or could have impacted patient care. FINDINGS: The surveyor requested the PIP program documents during the entrance conference on 06/06/2023. A review of documents provided by the Administrator on 06/14/2023 at 1:50 PM revealed Professional Advisory Committee meetings dated: 01/10/21; 01/15/22 and 01/11/2023. No evidence of performance improvement projects for 2020, 2021 and 2022 was provided. In an interview with the Administrator on 06.20.23 at approximately 1:00 PM, the surveyor reviewed the findings and asked about the lack of Performance Improvement Projects. The Administrator stated, “since COVID, we have not had anything done, the consultant has not been here (in the agency).” Agency Policy, quoted in part, dated 070711, “PERFORMANCE IMPROVEMENT PROCESS… QAPI.3, PURPOSE: Data is collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement. POLICY: The Agency will collect data to monitor performance of areas targeted for study and to determine effectiveness of the change….”