Every finding on record at West Carroll Health Systems, Inc.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: PIP- Performance Improvement Project QA- Quality Assurance QAPI- Quality Assurance Performance Improvement OASIS- Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) assessment for 8 of 15 patients reviewed for timely submission to the CMS system. Findings: Review of the provider’s CMS Submission Report OASIS Agency Final Validation Report with Submission date of 11/24/2025 revealed documentation of 12 records with 7 of the records processed and submitted late due to a submission date of more than 30 days after the assessment was completed. Review of the provider’s CMS Submission Report OASIS Agency Final Validation Report with Submission date of 12/16/2025 revealed documentation of 3 records with 1 of the records processed and submitted late due to a submission date of more than 30 days after the assessment was completed. Interview on 12/17/2025 at 2:00 p.m. with S1Administrator confirmed 8 of 15 OASIS assessments were not processed and submitted to the state within 30 days.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to meet the requirements of the Condition of Participation: Quality Assessment and Performance Improvement (QAPI) by failing to develop, implement, evaluate, and maintain an effective, ongoing, Home Health Agency-wide, data-driven QAPI program. This deficient practice was evidenced by the Home Health Agency failing to have documentation of: 1.) measurable improvement indicators of health outcomes, patient safety, and quality of care (See findings in G0642); 2.) quality indicator data, including measures derived from OASIS and other relevant data (See findings in G0644); 3.) performance improvement activities and tracking of adverse patient events (See findings in G0654); 4.) performance improvement projects (See findings in G0658); and 5.) oversight by the Home Health Agency governing body to ensure there was an ongoing program for quality improvement to conduct an agency wide assessment and establish, implement, and maintain clear expectations for patient safety (See findings in G0660). Findings: See findings in G642, G644, G654, G658 and G660.

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 reviews and interviews, the Home Health Agency failed to have documentation of measurable improvement indicators of health outcomes, patient safety, and quality of care in their QA program. Findings: Review of the agency’s documentation of QA dated 12/16/2024 revealed no documented evidence of measurable improvement indicators of health outcomes, patient safety, and quality of care in their QA program. In an interview on 12/17/2025 at 4:45 p.m. with S1Administrator, she confirmed the agency had not documented measurable improvement indicators of health outcomes, patient safety, and quality of care in their QA program.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the Home Health Agency failed to provide documentation of quality indicator data, including measures derived from the OASIS and other relevant data in their QA program. Findings: Review of the agency’s documentation of QA dated 12/16/2024 revealed no documented evidence of quality indicator data, including measures derived from the OASIS and other relevant data. In an interview on 12/17/2025 at 4:45 p.m. with S1Administrator, she confirmed the agency had not included quality indicator data, including measures derived from the OASIS and other relevant data in their QA.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the Home Health Agency failed to have documentation of performance improvement activities that track adverse patient events, analyze their causes, and implement preventive actions in their QA. Findings: Review of the agency’s documentation of QA dated 12/16/2024 revealed no documented evidence of performance improvement activities that track adverse patient events, analyze their causes, and implement preventive actions in their QA. In an interview on 12/17/2025 at 4:45 pm with S1Administrator, she confirmed the agency had not included performance improvement activities that tracked adverse patient events, analyzed their causes, and included preventive actions to address the identified causes in their QA.

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 record reviews and interviews, the Home Health Agency failed to have documentation of performance improvement projects in their QA. Findings: Review of the agency’s documentation of QA dated 12/16/2024 revealed no documented evidence of performance improvements projects in their QA. In an interview on 12/17/2025 at 4:45 p.m. with S1Administrator, she confirmed the Home Health Agency's QA had not included identification of issues in need of improvement as their performance improvement projects in their QA plan.

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 reviews and interviews, the Home Health Agency failed to have documentation in their QA process of oversight by the Home Health Agency governing body to ensure the following: 1.) there was an ongoing program for quality improvement and patient safety, 2.) the agency quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness, 3.) clear expectations for patient safety were established, implemented, and maintained and 4.) that any findings of fraud or waste were appropriately addressed. Findings: Review of the agency’s documentation of QA dated 12/16/2024 revealed no documented evidence of oversight by the Home Health Agency governing body to ensure the following: 1.) there was an ongoing program for quality improvement and patient safety, 2.) the agency quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness, 3.) clear expectations for patient safety were established, implemented, and maintained and 4.) that any findings of fraud or waste were appropriately addressed. In an interview on 12/17/2025 at 4:45 p.m. with S1Administrator, she confirmed the agency had no documentation of the Home Health Agency’s Governing Body oversight of the provider’s QA program. S1Administrator also confirmed the Governing Body failed to ensure there was an ongoing program for quality improvement and patient safety, that the agency’s quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, that all improvement actions were evaluated for effectiveness, that clear expectations for patient safety were established, implemented, and maintained, and that there was a system in place to address any findings of fraud or waste.