West Carroll Memorial Hospital Home Health

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.

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.

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.

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.

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.

The Home Health Agency failed to have documentation of performance improvement projects in their QA.

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…