| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017050 | (X3) Date Survey Completed 01/06/2023 |
| Name of Provider or Supplier Central North Alabama Health Services, Inc. | Street Address, City, State 1310 Pulaski Pike, Unit A, Huntsville, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| G0658 | 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 review of the facility's Quality Assessment, Performance Improvement (QAPI) program, and interview, it was determined the facility failed to conduct a performance improvement project (PIP) annually. Findings include: A review of the facility's QAPI program was conducted 1/6/23 at 1:56 PM with Employee Identifier (EI) # 1, Registered Nurse Administrator, and EI # 2, Compliance Officer. Review of the PIP documentation revealed there was no current agency PIP, and the last PIP initiated was on 5/6/19, which was three years prior to the current review. During the QAPI program review on 1/6/23, EI # 2 confirmed at 2:21 PM there was no other documentation of PIPs initiated by the agency. |