Home Health Services

Find out more about CPS services for Home Health

Home care (home health, hospice, home and community-based services and private duty) has a unique opportunity to help move patient safety forward. It is the fastest growing sector in healthcare today. Based in the patient’s home, this care setting could be the foundation for improving population health and preventing readmissions.

Since the IOM released its landmark report in 1999, most of the patient safety research has been centered within hospital walls. This year, the National Patient Safety Foundation (NPSF) presented eight recommendations to assist with moving patient safety forward, one of which addresses patient safety across the entire care continuum. Home care is poised to address patient safety, regardless of setting, as its professionals interact on a daily basis with multiple disciplines of healthcare.

Home care has its own unique challenges. Since it is based in the patient’s home and not a controlled environment, the home care professional must find the balance between what is safe and best for the patient within the environment created by the patient and their family. However, many of the patient safety events that occur in hospitals also occur in the patient’s home, including events such as falls, medication events, device events, healthcare-acquired infections and pressure ulcers. However, other potential safety hazards exist in homes that are not present within hospital walls, creating barriers to patient and healthcare worker safety. Examples are unsanitary conditions, cigarette smoke, aggressive pets, clutter to the point of hoarding, or insect infestations. To truly move home care forward in the area of patient safety, research must be completed to assess barriers in the home care arena, which are not present in a traditional healthcare setting.

The other area where home care can help push patient safety forward is in patient safety culture. The NPSF stated in its recommendations that leaders should establish and sustain a safety culture. As the NPSF affirmed, improving patient safety requires an organizational culture that enables and prioritizes patient safety. While safety activities and processes are important, they will not last or be engrained in daily activities until leadership makes patient safety a priority and supports a culture of patient safety.

The Center for Patient Safety is committed to promoting safe and quality healthcare, helping providers design safer processes and systems to reduce medical errors. Driven by the vision of a healthcare environment safe for all patients and healthcare providers, in all processes all the time, the Center serves as a central resource and facilitator to improve the safety and quality of care provided to citizens using a collaborative approach to education, information, resource sharing and learning.

One of the Center’s major tools to identify opportunities for improvement is the PSO database where the participants share events, near misses, unsafe conditions and lessons learned through root cause analyses. This year the Center’s annual PSO report highlights how patient safety isn’t just hospital-based, but rather is carried across the healthcare continuum. Over 400 events within the home care arena were analyzed, which indicates falls and medication errors are highly recurring patient safety events.

What does the future hold for the Center for Patient Safety, home care and patient safety? The goal is for home care providers to take a pledge to establish a culture of patient safety and begin routine implementation of processes that promote patient safety. The Center will continue to reach out and serve as a resource to organizations and focus on three objectives:

  1. Protecting – personal guidance on how to best protect patient safety and quality analysis and deliberations
  2. Learning – new opportunities for PSO participants to improve patient safety culture and implement best practices
  3. Preventing – improved analyses of the PSO database to identify opportunities for providers to reduce adverse events and patient harm

We at the Center are excited to be working with home care providers as we strive to improve patient safety for all individuals across the healthcare continuum.

Find out more about CPS services for Home Health


Providing Support and Federal Confidentiality Protection for Your QAPI work

State and federal protections for your quality and resident safety work have gaps that may limit a facility’s ability to fully implement the anticipated Quality Assurance and Performance Improvement standards in a confidential environment.  A Patient Safety Organization (PSO) such as the Center for Patient Safety offers more global protection for interdisciplinary and inter-organizational work across the continuum of care.

Download our LTC PSO Brochure

Find out more about all of services the Center for Patient Safety offers for Long-term Care

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Benefits of working with CPS:

The CPS is a leader in PSO services for hospitals, EMS providers and now long-term care.  We offer a data system customized for long-term care data collection and offer you opportunities to participate in learning and collaboration to improve safety for your organization.

In addition, as a participant with CPS, you will receive:

  • Access to a comprehensive toolkit to support your PSO work
  • Guidance on developing your facility’s policies for working with the PSO and assistance with setting up your own Patient (Resident) Safety Evaluation System
  • Ability to access facility-specific reports for analysis and comparison
  • Resources to assess your culture of safety and tools to improve it
  • Opportunities to collaborate with other long-term care providers AND OTHER PROVIDERS ON THE CARE CONTINUUM in a protected environment

Contact us for more information.

What Can Your Facility Protect?
  • Resident-safety events and related materials reported to the CPS
  • Work product of your Quality Assurance Committee, regardless of its composition.  Contributions from non-licensed staff have full protection.
  • Any deliberations and analysis directed to the ongoing improvement in the safety and quality of care for residents, whether or not it is part of the QA committee’s direct work
  • Internal studies of falls, medication events or other types of errors
  • Studies that identify areas that need performance improvement work
  • Collaborative safety efforts with other providers:  attending physicians, referring hospitals, EMS

Fees for PSO participation

Our fees are reasonable.

Attention Missouri-licensed long-term care facilities:  You may participate at no charge under a grant from the Missouri Foundation for Health (MFH).

Where do I begin?

Participation with the CPS PSO begins with a contract. The contract establishes your relationship with the PSO, expectations, and your agency’s intent to report medical error data to the PSO. Our staff will assist you with understanding the contract and begin your initial education on PSOs and what you need to know to work with us.

Contact us for more information!

Court Cases Addressing PSO Protections

Read about the multiple court cases upholding PSO protections and find out what is necessary to ensure your protections are maintained.

Want more information?

Contact anyone on our PSO Team:

Kathy Wire, JD, MBA, CPHRM, Project Manager, [email protected]
Lee Varner, BS EMS, EMT-P, Project Manager, EMS Services, [email protected]
Eunice Halverson, MA, Patient Safety Specialist, [email protected]
Tina Hilmas, RN, BSN, Project Manager, [email protected] 
Alex Christgen, BSBA, Project/Operations Manager and Analyst, [email protected]
Michael Handler, MD, MMM, FACPE, Medical Director
Amy Vogelsmeier, PhD, RN, GCNS-BC, Patient Safety Researcher/Analyst


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.