Every finding on record at Ahni Health Services Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 08/13/24. 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 08/13/24. An entrance conference was conducted with Staff A. Staff A 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 as a result of the re-certification survey. Glossary: OASIS- Outcome and Assessment Information Set QAPI- Quality Assessment Performance Improvement

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 plan of care for two (Patients #5 and 6) of 7 patients. Patient #5 A review of the plan of care dated 05/14/24 to 07/12/24 showed a primary diagnosis of heart failure and showed no individualized plan of care development of all services necessary for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 04/24/24 to 06/22/24 showed a primary diagnosis of congestive heart failure and showed no individualized plan of care development of all services necessary for the management of the primary diagnosis. On 08/13/24 at 2:20 pm., Staff A stated the plan of care should have been fully developed for the primary diagnosis for Patients #5 and 6.

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 a change in wound status for one (Patient #4) of seven patients. Patient #4 A review of the plan of care dated 05/22/24 to 07/20/24 showed a primary diagnosis of encounter for change or removal of nonsurgical wound dressing and documented a skilled nurse frequency of two visits per week for one week and two to three visits per week for eight weeks. Orders showed to provide wound care to the sacral area, every other day to cleanse wound with normal saline, apply skin prep to peri wound, apply plex foam dressing to wound bed, cover with dressing and secure with tape and to assess skin status and notify physician of significant changes. A review of the clinical record showed the following: A skilled nurse assessment dated 06/03/24 documented a wound to the sacral area with measurements of 1 centimeter long by 1 centimeter wide and 0.5 centimeters deep. A skilled nurse assessment dated 07/01/24 documented a wound to the sacral area with measurements of 1.5 centimeters long by 15 (charting error for 1.5) centimeters wide and 0.5 centimeters deep with no physician notification of a change in the wound status. A skilled nurse assessment dated 07/08/24 documented a wound to the sacral area with measurements of 2 centimeters long by 1.5 centimeters wide and 0.5 centimeters deep with no physician notification of a change, since 05/24/24, in the wound status. A skilled nurse assessment dated 07/15/24 documented a wound to the sacral area with measurements of 2 centimeters long by 1.5 centimeters wide and 0.5 centimeters deep with no physician notification of a change, since 05/24/24, in the wound status. On 08/13/24 at 2:15 pm., Staff A stated the physician should have been notified of change in the wound status for Patient #4.

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 30 current patients and all employees. A review of administrative records showed no OASIS data collection activities utilized in the agency's QAPI Program for calendar year of 2023 and from January 01, 2024, to August 13, 2024. On 08/13/24 at 2:40 pm, Staff A stated they had no analysis of OASIS data available that showed improved quality of patient care for 2023 and from January 01, 2024, to August 13, 2024.

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 initiation and review of a performance improvement project through their QAPI Program for 30 patients and all employees. A review of QAPI records showed no review, data analysis, or status of performance improvement projects for the calendar year of 2023 and January 01, 2024, to August 13, 2024. On 08/13/24 at 2:40 pm., Staff A stated the agency had no documented performance improvement project review, data analysis of the effectiveness of the performance improvement project or status of the current performance improvement project for 2023 and from January 01, 2024, to August 13, 2024.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 08/16/21 to 08/17/21. 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), §485.625(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 development of a community-based risk assessment (All Hazards Risk Assessment) for 39 patients and all employees. Findings: A review of administrative records showed no community-based risk assessment and no documentation of a community-based which addressed the agency, its patient population, or its employees. Requests for additional records yielded no records. On 08/17/21 at 11:00 a.m., Staff B stated there was no emergency preparedness community based risk assessment which addressed the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 08/16/21 through 08/17/21. 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 issues and Staff B was identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: POC Plan of Care

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile was reviewed and updated with an end date for an ordered medication for one (Patient #7) of 7 patients. Findings: Patient #7 A review of a POC dated 07/10/21 to 09/07/21 showed orders for permethrin 5% topical application daily. The documentation showed no communication with the physician and no update to the medication profile for the medication as a one time dose application. On 08/17/21 at 10:00 a.m., Staff C stated the medication was a one time dose application and should have included direction for one time use on the medication profile.

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 included interventions and goals related to the primary diagnosis for one (Patient #3) of seven patients. Findings: Patient #3 A review of a POC dated 07/08/21 to 09/05/21 documented a principal diagnosis of Stage III pressure ulcer to the left buttock. Documentation showed no patient care interventions or goals related to the principal diagnosis. On 08/17/21 at 10:00 a.m., Staff C stated the POC for Patient #3 did not document required patient care interventions or goals related to the principle diagnosis for home health.

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 visits were conducted per POC ordered frequency for two (Patient #5 and #6) of seven patients. Findings: Patient #5 A review of the POC dated 06/13/21 to 08/16/21 showed a SN frequency of two times a month for two months, then one time a month for one month. Documentation showed a SN visit was conducted on 06/22/21 (one visit missed between 06/13/21 and 06/30/21). Documentation showed no second SN visit scheduled or conducted during 06/13/21 and 06/30/21, no physician notification of the missed visit and no change in orders. Patient #6 A review of the POC dated 07/08/21 to 09/05/21 showed a SN frequency of two times a month for two months, then one time a month for one month. Documentation showed a SN visit conducted on 07/19/21 (one visit missed between 07/08/21 and 07/30/21). Documentation showed no second SN visit scheduled or conducted during 07/08/21 and 07/30/21, no physician notification of the missed visit and no change in orders. On 08/17/21 at 10:00 a.m., Staff C stated missed SN visits for Patient #5 and #6 should have been conducted as ordered on the POC.

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 discharge summary was provided for two (Pt's #1 and #2) of two patients. Findings: Patient #1 A review of the clinical record showed the patient was discharged from the agency on 06/22/21 to in-patient hospital care services. Documentation showed no discharge summary was provided to the hospital service provider. Patient #2 A review of the clinical record showed the patient was discharged from the agency on 04/12/21 to in-patient hospital care. Documentation showed no discharge summary was provided to the hospital service provider. On 08/17/21 at 10:00 a.m., Staff C stated no discharge summary was sent to the hospital service providers for Patient #1 and #2.