Every finding on record at Quality Home Health Care Inc

A recertification survey was conducted by Healthcare Licensing and Surveys from 1/9/23 to 1/11/23.

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 review of the agency's quality program, staff interview and review of the agency's Quality Assessment and Performance Improvement (QAPI) policy, the agency failed to measure, analyze and track quality indicators for the last 6 months of 2022. The findings were: 1. Review of the QAPI binder showed the last meeting was held 7/1/22 and was the second of two meetings held in 2022. Further review showed no evidence of an ongoing, agency-wide quality assessment and process improvement program to measure, analyze, and track quality indicators since 7/1/22. 2. Interview with the administrative assistant on 1/11/23 at 9 AM confirmed the QAPI program had not been kept up-to-date. 3. Review of the agency's policy "Quality Assessment and Performance Improvement (QAPI) Plan and Program", updated, showed "The Agency will establish an ongoing, Agency-wide, data driven program of quality assessment and performance improvement...To continuously collect and analyze data to improve Agency's performance of clinical and other processes..."

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview the agency failed to ensure home health aide (HHA) supervisory visits were completed at least every 60 days for 5 of 7 sample patients (#1, #2, #4, #6, #8) that received HHA services. The findings were: 1. Review of the plan of care for patient #1, dated 11/26/22 to 1/24/23 showed orders for a HHA 3 times a week and a start of care date of 7/29/22. Further review showed one supervisory visit this certification period on 12/21/22 and the previous supervisory visit was on 10/17/22 (greater than 60 days apart). 2. Review of the plan of care for patient #2, dated 11/1/22 to 12/30/22 showed orders for a HHA 2-3 times a week and a start of care date of 11/11/20. Further review showed one supervisory visit this certification period on 12/21/22 and the previous supervisory visit was on 8/28/22 (greater than 60 days apart). 3. Review of the plan of care for patient #4 dated 11/26/22 to 1/24/23 showed orders for a HHA 3 times a week and a start of care date of 12/12/19. Further review showed one supervisory visit during this certification period on 12/21/22, no evidence of a supervisory visit for the 2021 calendar year, and one supervisory visit on 3/26/20. 4. Review of the plan of care for patient #6 dated 11/29/22 to 1/27/23 showed orders for a HHA 2-3 times a week and a start of care date of 2/2/22. Further review showed one supervisory visit on 1/4/23 and no evidence of a previous supervisory visit of the HHA since the start of care. 5. Review of the plan of care for patient #8 dated 11/25/22 to 1/23/23 showed orders for a HHA 5 times a week and a start of care date of 6/29/16. Further review showed the last supervisory visit of the HHA was on 10/28/22 and there was no evidence of another one since that date. 6. Interview with the administrative assistant on 1/11/23 at 11:05 AM confirmed that supervisory visits were documented in the electronic health record of each patient under the "supervisory visit" tab if they had been completed.