Every finding on record at Alpha Healthcare Services, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/07/24 to 05/09/24. 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 development of a community-based risk assessment (All Hazards Risk Assessment) for 10 patients and current employees. A review of administrative records showed no community-based risk assessment which addressed the agency, its patient population, or its employees. On 05/09/24 at 1:35 p.m., Staff A stated the agency had no emergency preparedness community-based risk assessment.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 05/07/24 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 and administrative 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: POC Plan of Care SN Skilled Nurse/Nursing HHA Home Health Aide

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was performed within 48 hours of the referral for two (Patients #5 and 6) of seven patients. Patient #5 A review of the clinical record showed a patient referral dated 02/08/24. A review of clinical documentation showed an initial patient assessment and SOC dated 02/15/24 (seven days later). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order to delay the initial assessment. Patient #6 A review of the clinical record showed a patient referral dated 01/17/24. A review of clinical documentation showed an initial patient assessment and SOC dated 01/22/24 (five days later). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order to delay the initial assessment. On 05/09/24 at 1:35 p.m., Staff A stated the initial assessment for Patients #5 and 6 were not completed within 48 hours of the referral.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN provided insulin treatment as ordered for one (Patient #2) of seven patients. Patient #2 A review of the POC dated 03/04/24 to 05/02/24 showed an order for SN to check blood sugar and administer insulin daily on Saturday and Sunday. A further review of a physician’s order dated 01/25/24 showed an order to use 16 units of insulin glargine daily and hold if blood sugar before breakfast is less than 100. A review of clinical records showed the following: A SN visit dated 04/06/24 showed a fasting blood sugar result of 98 and 16 units of insulin glargine was administered to left lower quadrant. A SN visit dated 04/07/24 showed a fasting blood sugar result of 93 and 16 units of insulin glargine was administered to right lower quadrant. On 05/09/24 at 1:19 p.m., Staff A stated the insulin treatment for Patient #2 was not followed as ordered by the physician.

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 the frequency and duration of visits to be made for three (Patients #3, 5 and 7) of seven patients. Patient #3 A review of a POC dated 01/12/24 to 03/11/24 showed a SN frequency of two times a week and no duration of visits. Patient #5 A review of a POC dated 02/15/24 to 04/14/24 showed a SN frequency of one time a week and no duration of visits. Patient #7 A review of a POC dated 01/27/24 to 03/26/24 showed no SN frequency and no duration of visits. On 05/09/24 at 1:25 p.m., Staff A stated the POC did not contain the duration of visits to be made for Patients #3, 5 and no frequency and duration of visits to be made for Patient #7.

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 PIP through their QAPI Program for 10 patients and current employees. A review of the agency’s documentation showed no records of performance improvement projects implemented, in development, on-going or completed for calendar year 2023 or from 01/01/24 to 05/09/24. On 05/09/24 at 1:40 p.m., Staff A stated the agency had no documentation which showed PIP activities for 2023 or from 01/01/24 to 05/09/24.

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: 1. HHA services were conducted as ordered for two (Patients #4 and 6) of seven patients; and 2. Social Worker service was conducted as ordered for one (Patient #6) of seven patients. 1. Patient #4 A review of the POC dated 01/22/24 to 03/21/24 showed an HHA frequency of twice a week within the 60 days episode, effective 01/22/24. Documentation showed no HHA visits were conducted, no patient/caregiver refusal of services, no physician notification and no changes in the order. Patient #6 A review of the POC dated 01/22/24 to 03/21/24 showed an order for HHA to assess and evaluate, effective 01/22/24. Documentation showed no HHA evaluation was conducted, no patient/caregiver refusal of services, no physician notification and no changes in the order. 2. Patient #6 A review of the POC dated 01/22/24 to 03/21/24 showed a medical social worker frequency of one time a week and no duration. Documentation showed no social worker service was conducted, no patient/caregiver refusal of services, no physician notification and no changes in the order. On 05/09/24 at 1:27 p.m., Staff A stated: 1. the HHA services for Patients #4 and 6 were not met as ordered by the physician; and 2. the medical social worker service for Patient #6 was not met as ordered by the physician.