Every finding on record at The University of Kansas Health System Home Health Great Bend, LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification (ASPEN #38859-H1) at the above-named Home Health Agency from 04/13/22 to 04/14/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (#38859-H1) at the above-named Home Health Agency from 04/13/22 to 04/14/22 resulted in a finding of substantial compliance respective to applicable COP under 42 CFR 484, Subpart A through C, with the following standard deficiency.

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 document review, policy review and interview, the governing body failed to ensure the agency maintained an ongoing program for quality improvement and patient safety for patients. The governing body’s failure to ensure executive responsibility for the agency’s ongoing quality assessment and performance improvement program, has the potential to place all patients at risk for compromised quality of care and patient safety. Findings Include: Review of a policy titled, "GBHHH-Governing Body, PolicyStat ID 6994901, Last Revised 10/2019," showed the GBHHH-Governing Body assumes full legal authority and responsibility for the overall management and operation, the provision of all home health/hospice services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program of GBHHH. Review of agency’s quality assessment and performance improvement program (QAPI) documentation showed the program failed to document and maintain written minutes to support review and approval of the agency’s QAPI program, by the agency’s governing body. During an interview on 04/14/22 at 11:45 PM, Staff A, Administrator, confirmed discussion with the agency’s governing body president, that affirmed the governing body failed to document and maintain written minutes of review and approval of the QAPI program as evidence of completion of executive responsibilities for the agency’s quality assessment and performance improvement program.