Every finding on record at Alpha Home Health Care LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/25/23 to 04/26/23. 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 04/25/23 to 04/26/23. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C and D. Standard level deficiencies were cited as a result of the survey. Glossary: CHHA certified home health aide EP Emergency Preparedness HHA Home Health Agency OT Occupational therapy PIP Performance Improvement Project PT Physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

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 pain reporting parameters for one (Patient #2) of eight patients. Findings: Patient #2 A review of a POC dated 04/04/23 to 06/02/23 showed a SN visit frequency of one time a week for nine weeks and for SN to assess and instruct on the patient’s pain. A review of clinical documentation showed no physician pain reporting parameters on the POC. Documentation showed patient reported pain levels during visits dated 04/04/23 and on 04/11/23. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 04/26/23 at 10:30 a.m., Staff B stated the POC for patient #2 did not include physician pain reporting parameters.

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 evidence of a patient centered QAPI Program for calendar year 2021 for all patients and employees. Findings: A request for QAPI records for 2021 and 2022 yielded documents for 2022. No documentation was provided for calendar year 2021. On 04/26/23 at 9:40 a.m., Staff B stated there was no documentation of an ongoing QAPI program for calendar year 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 QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A request for QAPI records for 2021 and 2022 yielded records for 2022. No documentation was provided for calendar years 2021. On 04/26/23 at 9:40 a.m., Staff B stated the agency had no QAPI records for calendar year 2021.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees. Findings: A request for QAPI records for calendar years 2021 and 2022 yielded no records for 2021. No records for 2021 were provided. On 04/26/23 at 9:40 a.m., Staff B stated the agency had no QAPI records for calendar year 2021.

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 in calendar year 2021 for all patients and employees. Findings: A request for QAPI and PIP records for 2021 and 2022 yielded no records for 2021. No documentation was provided for calendar year 2021. On 04/26/23 at 9:40 a.m., Staff B stated the agency had no QAPI or PIP records for calendar years 2021.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities in calendar year 2021 for all patients and employees. Findings: A request for governing body, QAPI and PIP records for calendar years 2021 and 2022 yielded no records for 2021. On 04/26/23 at 9:40 a.m., Staff B stated the agency had no documentation which showed governing body oversite of QAPI Program activities for calendar year 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: its infection control program included surveillance monitoring and reporting and was included in QAPI program activities for calendar years 2021 for all patients and staff. Findings: A request for infection control records for calendar years 2021 and 2022 yielded no documents for calendar year 2021. On 04/26/23 at 9:40 a.m., Staff B stated the agency had no infection control or QAPI data for calendar year 2021.

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 services were provided as ordered on the POC for: SN to visit frequencies as ordered by the physicians for one (Patient #1) of eight patients; OT evaluations for two (Patients #2 and #3) of eight patients; PT visit frequency for two (Patients #3 and #5) of eight patients. Findings: Patient #1 A review of a POC dated 03/22/23 to 05/20/23, showed orders for a SN visit frequency of one time a week for nine weeks. A review of clinical documentation showed: during the week of 03/26/23 to 04/01/23 no SN visit was conducted (one visit ordered, no visit conducted); week of 04/02/23 to 04/08/23 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no attempts to conduct the SN visits, no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 04/26/23 at 10:25 a.m., Staff B stated the SN visits should have been provided and conducted by the agency. Patient #2 A review of a POC dated 04/04/23 to 06/02/23, showed orders for an OT evaluation once time a week for one week, during week of 04/04/23 to 04/08/23. Documentation showed an OT evaluation was conducted during the week 04/09/23 to 04/15/23 on 04/11/23. Documentation showed no attempts to complete the OT evaluation during week of 04/04/23 to 04/08/23, no patient/caregiver refusal of the OT evaluation, no physician notifications and no change in orders. On 04/26/23 at 10:30 a.m., Staff B stated the OT evaluation should have been provided and conducted by the agency as ordered. Patient #3 A review of a POC dated 03/10/23 to 05/08/23, showed orders for PT visit frequency of one time a week for one week, two times a week for two weeks, then one time a week for one week. Documentation showed during the week of 03/19/23 to 03/25/23 a visit was conducted on 03/21/23 (one visit conducted, two visits ordered) and; POC showed orders for an OT evaluation once time a week for one week, during week of 03/12/23 to 03/18/23. Documentation showed no OT evaluation was conducted. Documentation showed no attempts to complete a second PT visit during the week of 03/19/23 to 03/25/23, no attempt to conduct an OT evaluation, no patient/caregiver refusal of the PT visit or the OT evaluation, no physician notifications and no change in orders. On 04/26/23 at 10:38 a.m., Staff B stated the PT visit and the OT evaluation should have been provided and conducted by the agency as ordered. Patient #5 A review of a POC dated 03/20/23 to 0518/23, showed orders for PT visit frequency of two times a week for one week, three times a week for three weeks, then two times a week for one week. Documentation showed during the week of 04/02/23 to 04/08/23 visits were conducted on 04/03/23 and 04/07/23 (two visits conducted, three visits ordered). Documentation showed no attempts to complete a third PT visit during the week of 04/02/23 to 04/08/23, no patient/caregiver refusal of the PT visit, no physician notifications and no change in orders. On 04/26/23 at 10:49 a.m., Staff B stated the PT visit should have been provided and conducted by the agency as ordered.

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: 1. CHHA visit notes were completed for one (Patient #1) of eight patients and; 2. PT clinical visit notes were completed for one (Patient #4) of eight patients. Findings: Patient #1 A plan of care dated 03/22/23 to 05/20/23 showed a principal diagnosis of neuralgia and orders for a CHHA visit frequency of one time a week for one week, then two times a week for two weeks. A review of visit notes showed CHHA visit notes dated 03/27/23 and 03/29/23 were not completed by the CHHA until 04/03/23. On 04/26/23 at 10:25 a.m., Staff B stated visit notes are to be completed and signed by staff within 24 hour of the visit. Patient #4 A review of a POC dated 03/14/23 to 05/12/23 showed orders for PT visits at a frequency of two times a week for nine weeks. A review of visit notes showed PT visits dated 04/18/23 and 04/20/23 were not completed and available in the patient’s clinical record. Documentation showed no communications related to late documentation completion and submission of the PT visit notes. On 04/26/23 at 10:42 a.m., Staff B stated the PT visit notes for patient #4 were not completed and submitted within 24 hour of the visit.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for calendar year 2021 for all patients and employees. Findings: Administrative records of multi-disciplined skilled professional staff participation in the agency’s QAPI program for calendar years 2021 and 2022 were requested. No documentation for calendar year 2021 was provided. On 04/26/23 at 9:40 a.m., Staff B stated the agency had no administrative record documentation which showed multi-disciplined skilled professional staff participation in ongoing QAPI program activities for calendar year 2021.