Every finding on record at Advocate Home Health Care Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/08/24 to 05/09/24. Standard 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 agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) was developed and implemented for the agency for all patients and employees. Findings: A review of administrative records showed no community-based risk assessment for the agency, its patient population, or its employees. On 05/09/24 at 1:00 p.m., Staff B stated the agency did not develop and implement a community based All Hazards Risk Assessment.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included the required current employee contact information for the agency, for all patients and employees. Findings: Administrative records showed no updated Emergency Preparedness Communication Plan which included current employee contact information for the agency. On 05/09/24 at 1:00 p.m., Staff B stated the Emergency Preparedness Communication Plan was not updated to include contact information for current employees of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with a complaint investigation for complaint #103180 at the agency on 05/08/24 to 05/09/24. 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 clinical issues and Staff B was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited related to the complaint. Condition level deficiencies were cited in the following areas: 484.60 Care planning, Coordination of services, Quality of care Glossary: CHHA certified home health aide EP Emergency Preparedness HHA Home Health Agency OT occupational therapy PT physical therapy POC Plan of Care SN skilled nurse ST speech therapy

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a discharge oasis was completed for one (Patient #1) of eight patients. Findings: Patient #1 A review of the clinical record showed a start of care date of 11/02/23. Documentation showed discharge from agency services on 12/23/23. Documentation showed no discharge OASIS assessment was completed. On 05/09/24 at 11:18 a.m., Staff B stated the discharge OASIS was not completed for patient #1.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a discharge summary for one (Patient #8) of eight patients. Findings: Patient #8 A review of the clinical record showed the patient was discharged from the agency on 12/14/23. Documentation showed a blank and unsigned discharge summary. On 05/09/24 at 12:15 p.m., Staff B stated patient #8 did not have a completed discharge summary.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC included: 1. Documentation of aide service provisions and goals for two (Patients #6 and #7) of eight patients and; 2. Identified a wound site location for one (Patient #7) of eight patients. This failed practice had the potential to affect the health and health care outcomes of 35 patients that required skilled care interventions to improve their health status. See Tag #G574. Based on record review and interview, the agency failed to ensure a physician order for catheter change intervals from weekly to monthly were a part of the patient’s plan of care for one (Patient #2) of eight patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve management of health conditions for all patients. See tag G576. Based on record review and interview, the agency failed to notify the physician of changes in health conditions for one (Patient #8) of eight patients. The failed practice had the potential to affect a patient’s health and wellbeing in the management of their health conditions for all patients. See tag G590. Based on record review and interview, the agency failed to ensure coordination of care with outside facility care staff for one (Patient #1) of eight patients. The failed practice had the potential to affect a patient’s response to health care interventions to meet health related outcomes for all patients. See tag G608. .

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 individualized patient POC included: 1. Documentation of aide service provisions and goals for two (Patients #6 and #7) of eight patients and; 2. Identified a wound site location for one (Patient #7) of eight patients. This failed practice had the potential to affect the health and health care outcomes of 35 patients that required skilled care interventions to improve their health status. Findings: Patient #6 A review of the POC dated 03/08/24 to 05/06/24 showed a frequency order for aide services two times a week for nine weeks but documented no aide service provisions or goals. Documentation showed aide visits were conducted on 03/11/24, 03/14/24, 03/18/24, 03/20/24, 03/25/24, 03/27/24, 04/01/24, 04/03/24, 04/08/24, 04/10/24, 04/15/24, 04/17/24, 04/22/24 and on 04/24/24. Documentation showed no physician notifications and no change in orders. On 05/09/24 at 11:18 a.m., Staff B stated the POC for patient #6 did not include aide service provisions or goals. Patient #7 A review of the POC dated 04/30/24 to 06/28/24 showed orders for SN to conduct wound site assessment and care every visit but did not identify the site location of the wound on the POC. Documentation showed a frequency order for aide services two times a week for nine weeks but documented no aide service provisions or goals. Documentation showed no physician notifications and no change in orders. On 05/09/24 at 11:32 a.m., Staff B stated the POC for patient #7 did not include aide service provisions or goals; and did not identify a wound site location.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physician order for catheter change intervals from weekly to monthly were a part of the patient’s plan of care for one (Patient #2) of eight patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve management of health conditions for all patients. Findings: Patient #2 A review of the POC dated 03/01/24 to 04/29/24 showed orders for foley catheter management, including catheter changes weekly. SN visit note documentation on 03/06/24, 03/08/24, 03/11/24 and on 03/13/24 documented foley catheter changes to occur monthly. Documentation showed no physician orders to change the foley catheter change interval from weekly to monthly. Documentation showed no physician notification and no changes in orders. On 05/09/24 at 11:32 a.m., Staff B stated the POC for patient #2 showed no physician order transcription into the clinical record, no physician notification, and no changes in orders.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of changes in health conditions for one (Patient #8) of eight patients. The failed practice had the potential to affect a patient’s health and wellbeing in the management of their health conditions for all patients. Findings: Patient #8 A plan of care dated 04/30/24 to 06/28/24 documented diagnoses of Diabetes Mellitus Type II and cardiomyopathy. Documentation showed orders for SN to perform assessment and monitoring of health conditions every visit. SN visit notes dated 10/26/23 showed a patient weight of 230 pounds with 2+ pitting edema, and a subsequent SN visit note dated 10/30/23 showed a patient weight of 237 pounds (weight gain of 7 pounds) and continued 2+ pitting edema. Documentation showed no physician provider notifications or coordination of care communications related to changes in the patient’s change in condition and no changes in orders. On 05/09/24 at 12:15 p.m., Staff B stated the agency did not notify the physician of changes in the patient’s condition.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care with outside facility care staff for one (Patient #1) of eight patients. The failed practice had the potential to affect a patient’s response to health care interventions to meet health related outcomes for all patients. Findings: Patient #1 A review of the POC dated 11/02/23 to 12/29/23 showed orders for SN to discontinue a PICC (intravenous access device) upon completion of antibiotic therapy treatment. Documentation showed a SN visit frequency of one time a week for eight weeks. Documentation showed a last SN visit dated 11/27/23 (intravenous antibiotic therapy ongoing) and showed no follow up SN visit after that date. Documentation showed a desk discharge from agency services on 12/23/23. Documentation showed no patient request to discontinue nursing services, no coordination of care communications with the patient care organization overseeing the patient’s care (VA services), no physician notifications that the patient had no SN visits after 11/27/23 while the antibiotic therapy was still ongoing and showed no changes in orders. Documentation related to complaint #103180 showed the patient had to return to the VA hospital services to have the PICC line discontinued after the course of antibiotic treatments were concluded and had to arrange pick up of the infusion pump equipment from the infusion company as the agency did not return to the patient’s residence. On 05/09/24 at 11:18 a.m., Staff B stated: 1. The patient requested no further SN visits after 11/27/23; 2. Documentation showed no patient request to discontinue nursing services, no coordination of care communications with the patient care organization overseeing the patient’s care (VA services), no physician notifications that the patient had no SN visits after 11/27/23 while the antibiotic therapy was still ongoing and showed no changes in orders.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: SN visit frequencies were conducted as ordered for five (Patients #1, 4, 6, 7 and #8) of eight patients; SN to discontinue a PICC (intravenous access device) at the conclusion of intravenous antibiotic therapy for one (Patient #1) of eight patients; SN to conduct wound site assessment with measurements weekly for one (Patient #2) of eight patients; Aide visit frequency was conducted as ordered for one (Patient #4) of eight patients; PT evaluation was conducted for one (Patient #7) of eight patients; OT evaluation was conducted for one (Patient #7) of eight patients and; ST evaluation was conducted for one (Patient #7) of eight patients. Findings: Patient #1 A review of the POC dated 11/02/23 to 12/29/23 showed orders for SN visit frequency of one time a week for eight weeks and SN to discontinue a PICC (intravenous access device) upon completion of antibiotic therapy treatment. Documentation showed no SN visits were conducted during the weeks of 12/03/23 to 12/09/23 (one visit ordered, no visit conducted), 12/10/23 to 12/16/23 (one visit ordered, no visit conducted), 12/17/23 to 12/23/23 (one visit ordered, no visit conducted). Documentation showed SN did not discontinue the PICC (intravenous access device) at the end of the antibiotic therapy treatments. Documentation showed no patient/caregiver refusal of SN visits, no physician notifications, and no change in orders. On 05/09/24 at 11:18 a.m., Staff B stated: 1. The patient requested no further SN visits after 11/27/23; 2. Documentation showed no patient request to discontinue nursing services, no coordination of care communications with the patient care organization overseeing the patient’s care (VA services), no physician notifications that the patient had no SN visits after 11/27/23 while the antibiotic therapy was still ongoing and showed no changes in orders. Patient #2 A review of the POC dated 03/01/24 to 04/29/24 showed orders for SN visit frequency of three times a week for nine weeks for wound site assessment and measurements weekly. Documentation showed no wound site measurements during SN visits on 03/04/24, 03/06/24, 03/08/24, 03/11/24 and on 03/13/24 (patient transferred to inpatient services on 03/15/24). Documentation showed no patient/caregiver refusal of wound site measurements, no physician notifications, and no change in orders. On 05/09/24 at 11:32 a.m., Staff B stated the SN visit documentation showed no measurements of the wound sites. Patient #4 A review of the POC dated 03/07/24 to 05/05/24 showed orders for SN visit frequency of one time a week for nine weeks and an aide visit frequency of two times a week for nine weeks. Documentation showed during the weeks of 03/07/24 to 03/09/24; no SN visit conducted (one visit ordered, no visit conducted) and one aide visit was conducted on 03/08/24 (two visits ordered, one visit conducted). Documentation showed no patient/caregiver refusal of SN or aide visits, no physician notifications, and no change in orders. On 05/09/24 at 11:50 a.m., Staff B stated the SN and aide should have conducted visits as ordered on the POC. Patient #6 A review of the POC dated 03/08/24 to 05/06/24 showed orders for SN visit frequency of one time a week for nine weeks. Documentation showed during the weeks of 03/08/24 to 03/10/24 no SN visit conducted (one visit ordered, no visit conducted) and 04/28/24 to 05/02/24 no SN visit conducted (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of SN visits, no physician notifications, and no change in orders. On 05/09/24 at 11:55 a.m., Staff B stated the SN should have conducted visits as ordered on the POC. Patient #7 A review of the POC dated 04/30/24 to 06/28/24 showed orders for SN visit frequency of one time a week for nine weeks, PT to evaluate and treat one week one, OT to evaluate and treat one week one and ST to evaluate and treat one week one. Documentation showed during the week of 04/30/24 to 05/04/24 no SN visit conducted (one visit ordered, no visit conducted), 04/30/24 to 05/09/24 no PT evaluation visit conducted (one visit ordered), no OT evaluation visit conducted (one visit ordered) and no ST evaluation visit conducted (one visit ordered). Documentation showed no patient/caregiver refusal of visits, no physician notification, and no changes in orders. On 05/09/24 at 12:05 p.m., Staff B stated the clinical record for patient #7 showed: 1. No SN visit was conducted week of 04/30/24 to 05/04/24 and; 2. No PT, OT or ST evaluation was conducted and documentation showed no referral to the therapy services company contracted with the agency to perform the evaluations. Patient #8 A review of the POC dated 10/20/23 to 12/18/23 showed orders for SN visit frequency of one time a week for nine weeks. Documentation showed during the weeks of 11/12/23 to 11/18/23 no SN visit conducted (one visit ordered, no visit conducted), 11/19/23 to 11/25/23 no SN visit conducted (one visit ordered, no visit conducted), 11/26/23 to 12/02/23 no SN visit conducted (one visit ordered, no visit conducted), and 12/03/23 to 12/09/23 no SN visit conducted (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of SN visits, no physician notifications, and no change in orders. On 05/09/24 at 12:15 p.m., Staff B stated the SN should have conducted visits as ordered on the POC.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the development of a home health aide care plan for two (Patients #4 and #7) of eight patients. Findings: Patient #4 A review of the clinical record showed no documented home health aide care plan for the episode of 03/07/24 through 05/05/23. POC documentation showed an aide visit frequency of two times a week for nine weeks. Documentation showed home health aide visits were completed on 03/08/24, 03/12/24, 03/15/24, 03/19/24, 03/22/24, 03/26/24, 03/29/24, 04/02/24, 04/05/24, 04/09/24, 04/12/24, 04/16/24, 04/19/24, 04/23/24 and on 04/26/24. Documentation showed no home health aide care plan, or receipt of assignment by the CHHA. On 05/09/24 at 11:50 a.m., Staff B stated the clinical record for patient #4 showed no documented home health aide care plan. Patient #7 A review of the clinical record showed no documented home health aide care plan for the episode of 04/30/24 through 06/28/23. POC documentation showed an aide visit frequency of two times a week for nine weeks. Documentation showed no home health aide visits were completed during the week of 04/30/24 to 05/04/24. Documentation showed no home health aide care plan, or receipt of assignment by the CHHA. On 05/09/24 at 12:05 p.m., Staff B stated the clinical record for patient #7 showed no documented home health aide care plan.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for one (Patient #6) of eight patients. Findings: Patient #6 A review of the POC dated 03/08/24 to 05/06/24 showed orders for showed a CHHA visit frequency of two times a week for nine weeks. A review of the clinical record showed CHHA supervisory visits were completed on 03/14/24 and showed no further documentation of aide supervision from 03/15/24 to 05/09/24 (date of clinical record review, 55 days). Documentation showed no patient refusal of supervisory visits, physician notification and no change in orders. On 05/09/24 at 12:05 p.m., Staff B stated the CHHA supervisory visits for patient #6 should be conducted every 14 days from the date of the last supervisory visit.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure an administrator or alternate administrator was available during all operating hours for all patients and employees. Findings: On 05/08/24 at 9:09 a.m., OSDH arrived at the agency to conduct a survey. Upon entrance to the agency a staff member identified as the Field staff Licensed Practical Nurse/schedular was observed as the only agency personnel available on site at the agency. Field staff Licensed Practical Nurse/schedular stated the administrator was not present. Telephone call attempts to reach the administrator and the designated alternate administrator by the Field staff Licensed Practical Nurse/schedular went unanswered from 09:09 a.m. until the administrator’s arrival to the agency at 11:15 a.m. Office operating hours for the agency are Monday through Friday 9:00 a.m. to 5:00 p.m. At 11:15 a.m., the administrator stated he was not aware of attempts to reach him by telephone and did not know why the designated alternate administrator was not available for survey.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer summary was provided to the receiving service provider for one (Patient #3) of eight patients. Findings: Patient #3 A review of the clinical record documented transfer from the agency on 03/18/24 to inpatient hospital services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. At 11:45 a.m., Staff B stated the transfer summary was not provided to the receiving service provider for patient #3.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/18/21 - 05/19/21. No deficiencies were were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with a complaint (OK00055811) survey at the agency on 05/18/21 - 05/19/21. 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 and clinical issues. Findings were discussed during an informal exit conference with Staff A. Deficiencies were cited as a result of the Medicare re-certification survey. No defiencies were cited as a result of the complaint survey. GLOSSARY: OASIS Outcome and Assessment Information Set PIP Performance Improvement Project PIPS Performance Improvement Projects P.I.P Performance Improvment Project QAPI Quality Assessment and Perfomance Improvement

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure investigation of complaints for three (Complainant #1, 2 and 3) of three complaints. Findings: A request for complaints, grievances, incidents and variance reports yielded documentation titled "P.I.P Form." The P.I.P Form contained sections labeled as follows: 1) Issue; 2) Date; 3) Plan; 4) Who implements; 5) When is the in-service scheduled; 6) Name; and 7) Date. A review of the forms showed the following: P.I.P Form #1 A review of the form showed an incomplete intake and incomplete investigation of a complaint. The surveyor was provided with additional documentation that showed the issue was a skilled nurse visit being rushed. The form showed no patient identification affiliated with the complaint, no specific allegation, no documentation, no investigation, no date of report, and no way to determine if the matter was fully investigated. P.I.P Form #2 A review of the form showed an incomplete intake and incomplete investigation of a complaint. The surveyor was provided with additional documentation that showed the issue was skilled nurse complaint. The form showed no patient identification affiliated with the complaint, no specific allegation, no documentation, no investigation, no date of report, and no way to determine if the matter was fully investigated. P.I.P Form #3 A review of agency complaint records showed an incomplete intake and incompletel investigation of a complaint. The surveyor was provided with documentation that showed the issue was false documentation. The form showed no patient or staff identification affiliated with the complaint, no specific allegation, no documentation, no investigation, no date of report, and no way to determine if the matter was fully investigated. On 05/19/2021 at 10:50 am, Staff A stated the complaint documentation did not contain all information necessary to determine if a complete investigation of the complaint had occurred.

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 an individualized patient POC contained specific pertinent orders for one (Pts #2) of seven patients. Findings: Pt #2 A review of the plan of care dated 04/11/21 to 06/09/21 showed a principal diagnosis of Pressure Ulcer other site, stage 4. A review of the POC showed: 1) wound care as ordered with no specifics on how wound care would be provided; 2) orders for catheter and drainage bag care and management which failed to document how often to change the indwelling foley catheter, the size of the catheter, or amount of fluid to place in bulb); 3) orders to change huber needle with no documentation of the gauge or length of huber needle; 4) orders to flush the catheter with no documentation of whether the flush was for an indwelling catheter, foley catheter, or port and no documentation of with what to flush the catcher or the amount of fluid to use. On 05/19/21 at 11:57 am, Staff A stated the POCs for Pts # 2 should have documented specific care and services provided to the patient.

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 PIPs were complete, clear, and reflective of the current PIP status for all patients and employees. Findings: PIP 2019 A review of administrative records showed an untitled PIP initiated July 11, 2019, which identified duplicate submission of OASIS. A review of the PIP documentation showed no: 1) number of duplicate OASIS submissions; 2) data to be collected to determine if interventions were effective; 3) how often data would be collected and analyzed; 4) the evaluation section failed to show reports or updates on duplicate OASIS submissions; 4) the current status of the PIP. On 05/19/21 at 9:40 am, Staff stated the PIPs were missing some of the needed data.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the agency's QAPI program. Findings: A review of administrative records for calendar year 2019 and 2020 showed no review and approval of the agency's QAPI program. On 05/19/21 at 10:40 am, Staff A stated the governing body minutes for 2019 and 2020 did not show specific approval of the QAPI program.