Every finding on record at Our Homecare, Inc.

An Emergency Preparedness recertification survey was initiated on 04/08/2026. Census: Licensed and Certified: 13 Licensed Home Health: 0 Personal Assistance Services: 0 The agency was in compliance with the Medicare Conditions of Participation for Emergency Preparedness and no deficiencies were cited.

A Recertification survey was initiated on 04/08/2026. Census: Licensed and Certified: 13 Licensed Home Health: 0 Personal Assistance Services: 0 Acroynym: PIP- Performance Improvement Project QAPI- Quality Assurance Performance Improvement DON- Director of Nurses

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 document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects for 2 (2024 and 2025) of 3 years of QAPI records reviewed. This failure potentially placed patients at risk of poor health outcomes when the agency failed to identify and address areas of the home health's program for which performance could be improved. FINDINGS INCLUDE: Review of the undated documentation regarding the agency's QAPI Program included no documentation to indicate the home health agency had developed, implemented and described the reasons for conducting the projects, or evaluated the measurable progress achieved for the years of 2024 and 2025. During an interview on 04/10/2026 at 1:30 PM, with the Administrator, the Surveyor reviewed the findings and asked if the agency had completed and documented any PIPs. The Administrator stated, "I called the consultant to ask about those and they told me I needed to buy their policies.” The surveyor asked who in the agency was responsible for ensuring the QAPI projects were completed. The Administrator stated that the DON completed the reviews for the client records and he (Administrator) did the rest of QAPI. The surveyor asked if he (Administrator) or anyone in the agency had completed the PIPs. The Administrator stated, “no, they (PIPs) weren’t done.” The Surveyor asked if the Administrator knew when the PIPs were to be completed. The Administrator stated, “I’m not sure, the consultants have taken care of those before, but we didn’t have any consultants in the agency (years) 2024 or 2025.” Agency policy dated 01/29/2020, quoted in part, “Quality Assessment Performance Improvement Plan, … Program Activities: … 2. Performance improvement activities must track adverse patient events, analyze their causes and implement preventative actions. Performance Improvement Projects: (Beginning January 13, 2018 the Agency will conduct performance improvement projects.) … Written documentation will contain: … 3. Outcomes of improvement projects, a. The QAPI working team will provide a written summary of all findings, program adjustments, outcomes and suggestions for further improvements or recommendations of program success and completion of the project. …”