Every finding on record at Starcrest Healthcare Services Inc

A Recertification survey entrance was conducted on 02/13/2023. Census: Licensed and Certified Home Health – 2

A Recertification survey entrance was conducted on 02/13/2023. Census: Licensed and Certified Home Health – 2 Definitions: HHSC – Health and Human Services DFPS - Dept of Family Protective Services PAS – Personal Assistance Services APS – Adult Protective Services QAPI – Quality Assessment Performance Improvement PIP- Performance Improvement Plan A/N/E - Abuse, Neglect, and Exploitation

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 QAPI program that was measurable through data to evaluate patient safety and quality of care in three (2020, 2021, and 2022) of the three years reviewed. This failure could place patients at risk of the agency being unable to identify potential problems and implement corrective actions to ensure the health and safety of the agency's patients. Findings include: Review of the agency’s QAPI binder provided by the Administrator included a document titled, “Clinical Record Review…Audit Period: 1st Biannual 2021.” The binder also included a document titled, “1st Biannual Report to the Governing Board 2021,” signed, not dated by Owner C and Owner D and PAS Supervisor B. The binder also included a document titled, “QAPI Data Analysis – Rational For QAPI/PIP Plan…1st Biannual 2021.” The document was signed and dated on 7/15/2021 by Owner C and Owner D. Also included in the QAPI binder was a “QAPI Action Plan,” signed and dated on 7/30/2021 by Owner C. The agency’s QAPI documentation did not contain evidence that the agency maintained an agency wide QAPI program in 2020, 2021, and 2022. There was no system that measured an analysis of a representative sample of services furnished to patients contained in both active and closed records. There was no review of negative patient outcomes or system that measured significant outcomes for optimal care, no review of the effectiveness and safety of skilled services provided, or determination that skilled services had been performed as ordered. There was no annual evaluation of the total operation in three (2020, 2021, and 2022) of the three years reviewed. In an interview with the Administrator on 02/13/2023 at 3:00 p.m., the Administrator stated the agency’s owner was also the previous administrator. The Administrator stated she called and asked Owner C if there was any additional QAPI documentation. The Administrator stated she was unable to find any additional QAPI documentation and no further documentation was provided. Review of the agency's QAPI policy, “Policy 5.0 Quality Assurance Performance Improvement Program,” read in part, “… Purpose: … The performance improvement plan, established by the senior management of the organization in collaboration with staff members … Policy: … is evaluated at least annually and revised as necessary … IV. Clinical Record Review: … 2. meets quarterly to review both active and discharged client records… Organization: … The Board of Directors has a responsibility to evaluate the effectiveness of the performance improvement activities performed throughout the agency and the organizational performance improvement program as a whole….”

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: Based on record review and interview, the agency’s license holder’s, Owner C and Owner D failed to ensure the agency implemented and maintained a QAPI program that was ongoing to monitor efforts to improve patient safety and evaluated for effectiveness for three (2020, 2021, and 2022) of three years reviewed. This failure could place patients at risk of the agency being unable to identify potential problems and implement corrective actions to ensure the health and safety of the agency's patients. Findings include: Review of the agency’s QAPI binder provided by the Administrator included a document titled, “Clinical Record Review…Audit Period: 1st Biannual 2021.” The binder also included a document titled, “1st Biannual Report to the Governing Board 2021,” signed, not dated by Owner C and Owner D and PAS Supervisor B. The binder also included a document titled, “QAPI Data Analysis – Rational For QAPI/PIP Plan…1st Biannual 2021.” The document was signed and dated on 7/15/2021 by Owner C and Owner D. Also included in the QAPI binder was a “QAPI Action Plan,” signed and dated on 7/30/2021 by Owner C. The agency’s QAPI documentation did not contain evidence that the agency maintained an agency wide QAPI program in 2020, 2021, and 2022. There was no review of both active and closed records, no review of negative outcomes, and no system to review the safety and effectiveness of skilled services provided. In an interview with the Administrator on 02/13/2023 at 3:00 p.m., the Administrator stated the agency’s owner was also the previous administrator. The Administrator stated she called and asked Owner C if there was any additional QAPI documentation. The Administrator stated she was unable to find any additional QAPI documentation and no further documentation was provided. Review of the agency's QAPI policy, “Policy 5.0 Quality Assurance Performance Improvement Program,” read in part, “… Purpose: … The performance improvement plan, established by the senior management of the organization in collaboration with staff members … Policy: … is evaluated at least annually and revised as necessary … IV. Clinical Record Review: … 2. meets quarterly to review both active and discharged client records… Organization: … The Board of Directors has a responsibility to evaluate the effectiveness of the performance improvement activities performed throughout the agency and the organizational performance improvement program as a whole….” The agency’s QAPI documentation did not contain evidence that the agency met quarterly in 2020, 2021, and 2022 and evaluated QAPI annually per the agency's policy.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the agency’s Governing Body, Owner C and Owner D, failed to assume the responsibility for the agency to maintain a QAPI program. This failure placed patients at risk poor outcomes from not ensuring the monitoring of patient safety, professional conduct, and the quality of health care provided. Findings: QAPI program: Review of the agency’s QAPI binder provided by the Administrator included a document titled, “Clinical Record Review…Audit Period: 1st Biannual 2021.” The binder also included a document titled, “1st Biannual Report to the Governing Board 2021,” signed, not dated by Owner C and Owner D and PAS Supervisor B. The binder also included a document titled, “QAPI Data Analysis – Rational For QAPI/PIP Plan…1st Biannual 2021.” The document was signed and dated on 7/15/2021 by Owner C and Owner D. Also included in the QAPI binder was a “QAPI Action Plan,” signed and dated on 7/30/2021 by Owner C. The agency’s QAPI documentation did not contain evidence that the agency maintained a QAPI program for 2020, 2021, and 2022. In an interview with the Administrator on 02/13/2023 at 3:00 p.m., the Administrator stated the agency’s owner was also the previous administrator. The Administrator stated she called and asked Owner C if there was any additional QAPI documentation. The Administrator stated she was unable to find any additional QAPI documentation and no further documentation was provided. Policies: Review of the agency's QAPI policy, “Policy 5.0 Quality Assurance Performance Improvement Program,” read in part, “… Purpose: … The performance improvement plan, established by the senior management of the organization in collaboration with staff members … Policy: … is evaluated at least annually and revised as necessary … IV. Clinical Record Review: … 2. meets quarterly to review both active and discharged client records… Organization: … The Board of Directors has a responsibility to evaluate the effectiveness of the performance improvement activities performed throughout the agency and the organizational performance improvement program as a whole….”