Every finding on record at Adair County Health Center, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/24/25. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for three patients and all employees. A review of administrative records showed no community-based risk assessment which addressed the agency and it's patient population. On 02/24/25 at 2:15 pm, Staff A stated there was no documentation of an all-hazards risk assessment.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency drills were completed for all employees and three current patients. A review of Emergency Preparedness and administrative records showed no Emergency Preparedness Tabletop Exercise or disaster drill completed for calendar years 2023 or 2024. On 02/24/25 at 2:15 pm, Staff A stated the agency was unable to provide a documented disaster drill or tabletop exercise for 2023 or 2024.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/24/25. An entrance conference was conducted with Staff A and B. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Deficiencies were cited as a result of the re-certification survey.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of notification of the potential for discharge for cause was provided to the patient for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no notification to the patient of need for discharge for cause. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. On 02/24/25 at 1:52 pm., Staff A stated Patient #10 was not provided information in regard to the potential for discharge for cause prior to the date of discharge.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of efforts to resolve the patient's behavior for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no behaviors or attempts to resolve unacceptable behaviors and no documentation of reason for potential discharge was provided to the patient. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. On 02/24/25 at 1:52 pm., Staff A stated Patient #10 was not informed of or provided the opportunity to correct unacceptable behaviors.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure it provided contact information to other agencies to provide care for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no issues which warranted a discharge for cause and did not provide contact information for other agencies to provide care. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. On 02/24/25 at 1:52 pm., Staff A stated Patient #10 was not provided contact information for other agencies to provide care.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the duration of skilled nurse visits was included on the plan of care for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. On 02/24/25 at 2:10 pm., Staff A stated the plan of care for Patient #10 did not include the duration of the visits to be provided.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were obtained and documented in the clinical record for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no behaviors or attempts to resolve unacceptable behaviors and no documentation of reason for potential discharge was provided to the patient. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. No orders were received for the discharge of the patient. On 02/24/25 at 2:00 pm., Staff A stated the clinical record for Patient #10 did not have any orders to discharge the patient.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/02/22. 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 03/02/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff C was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the re-certification survey: GLOSSARY: QAPI Quality Assessment and Performance Improvement OASIS Outcome and Assessment Information Set

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of an individualized plan of care for one (Patient #1) of seven patients. Patient #1 A review of the plan of care dated 12/22/21 to 02/19/22 showed a primary diagnosis of non-pressure ulcer of left calf limited to skin breakdown and documented a skilled nurse frequency of one visit per week for eight weeks. The plan of care documented no interventions for the assessment of the wound. A review of the electronic medical record showed the following: A skilled nurse assessment dated 12/27/21 documented no wound assessment. A skilled nurse assessment dated 01/06/22 documented no wound assessment. A skilled nurse assessment dated 01/10/22 documented no wound assessment. A skilled nurse assessment dated 01/19/22 documented no wound assessment. A skilled nurse assessment dated 01/25/22 documented no wound assessment. A skilled nurse assessment dated 01/31/22 documented no wound assessment. A skilled nurse assessment dated 02/08/22 documented no wound assessment. A skilled nurse assessment dated 02/16/22 documented no wound assessment. On 03/02/22 at 1:40 pm., Staff C stated the plan of care for Patient #1 should have documented interventions for the assessment and monitoring of wound.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure weights were obtained as ordered for one (Patient #4) of 7 patients. Patient #4 A review of the plan of care dated 12/16/21 to 02/13/22 showed a primary diagnosis of congestive heart failure and documented a skilled nurse frequency of one visit per week for eight weeks with orders for skilled nurse to obtain daily weights. A review of the electronic medical record showed the following: A skilled nurse assessment dated 12/21/21 with no weight documented. A skilled nurse assessment dated 12/28/21 with no weight documented. A skilled nurse assessment dated 01/06/22 with no weight documented. A skilled nurse assessment dated 01/11/22 with no weight documented. A skilled nurse assessment dated 01/18/22 with no weight documented. A skilled nurse assessment dated 01/27/22 with no weight documented. A skilled nurse assessment dated 02/09/22 with no weight documented. On 03/02/22 at 1:10 pm, Staff C stated the order for the skilled nurse to obtain weights was not followed for Patient #4.

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 review and interview, the agency failed to ensure documentation of a patient centered QAPI Program for all patients and employees. A review of administrative records showed no documentation of an ongoing patient centered QAPI program for 2019, 2020 and 2021. On 03/02/21 at 2:2 pm, Staff A and D stated there was no documentation of a QAPI program for 2019, 2020 and 2021.

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 review and interview, the agency failed to ensure utilization of OASIS data to improve program effectiveness, quality of patient care and overall program improvement for all future patients. A review of administrative records showed no OASIS data collection activities utilized in the agency's QAPI Program for calendar years of 2020 and 2021. On 03/02/22 at 2:20 pm, Staff A stated they had no analysis of OASIS data available that showed improved quality of patient care for 2020 and 2021.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Infection Control Program included interventions to reduce future infections and promote learning and preventative measures throughout the agency for all 27 patients and all staff. A review of administrative records showed no ongoing infection control program to reduce future infections and provide preventative measures throughout the agency for calendar year's 2019, 2020 and 2021. On 03/02/22 at 2:20 pm, Staff A stated the agency had no comprehensive infection program in place to reduce future infections and provide preventative measures for 2019, 2020 and 2021.