Every finding on record at A Premier Senior Home Care Acquistions, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/11/24 to 03/12/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/11/24 to 03/12/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B was identified as the contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff B. Standard level deficiencies were cited as a result of the survey. Glossary: PT physical therapy PIP performance improvement project QAPI Quality Assessment and Performance Improvement SN skilled nurse

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 review and interview, the agency failed to ensure the review and reporting of ongoing PIP data through the QAPI program for all patients and employees. Findings: A review of QAPI program documents showed no PIP data reporting for first through third quarters calendar year 2022 and third and fourth quarter’s calendar year 2023. On 03/12/24 at 2:30 p.m., Staff B stated QAPI program documentation showed no reporting of PIP data for first through third quarters calendar year 2022 and third and fourth quarter’s calendar year 2023.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure PT visit note documentation was completed within 48 hours of the visit for two (Patients #4 and #9) of nine patients. Findings: Patient #3 A review of the POC dated 02/11/24 to 04/10/24 showed orders for PT visit frequency of two times a week for four weeks. Documentation showed PT visit dated 03/06/24 was completed on 03/11/24 (five days from the date of the visit). Documentation showed no documentation as to why the visit note was not completed within 48 hours of the visit. On 03/12/24 at 3:00 p.m., Staff B stated: 1. Visit note documentation is due 24 to 48 hours from the time a visit is completed and; 2. PT visit documentation was not completed timely for patient #3. Patient #9 A review of the POC dated 01/09/24 to 03/08/24 showed orders for PT visit frequency of two times a week for nine weeks. Documentation showed PT visit dated 01/11/24 was completed on 01/16/24 (five days from the date of the visit), 01/17/24 was completed on 01/23/24 (six days from the date of the visit), 01/29/24 was completed on 02/05/24 (five days from the date of the visit) and 01/31/24 was completed on 02/05/24 (five days from the date of the visit). Documentation showed no documentation as to why the visit notes were not completed within 48 hours of the visits. On 03/12/24 at 3:15 p.m., Staff B stated: 1. Visit note documentation is due 24 to 48 hours from the time a visit is completed and; PT visit documentation was not completed timely for patient #9.