Every finding on record at Baptist Healthcare of Oklahoma LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/05/24 to 11/07/24. 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 a community-based risk assessment (All Hazards Risk Assessment) was implemented and reviewed for the agency for all patients and employees. Findings: A review of administrative records showed no community-based risk assessment (All Hazards Risk Assessment) for the agency its patients and employees. On 11/07/24 at 9:00 a.m., Staff B stated the agency did not have a community-based risk assessment (All Hazards Risk Assessment) for the agency.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were documented (after action summary response) from 05/12/23 to 12/31/23; and 01/01/24 to 11/07/24 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no documentation (after action summary response) of emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for from 05/12/23 to 12/31/23; and 01/01/24 to 11/07/24. On 11/07/24 at 9:00 a.m., Staff B stated the emergency preparedness program for the agency showed no documentation (after action summary response) of emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for from 05/12/23 to 12/31/23; and 01/01/24 to 11/07/24.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 11/05/24 to 11/07/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff B and C. Standard level deficiencies were cited as a result of the survey. Glossary: OT occupational therapy PT physical therapy POC plan of care PIP performance improvement project QAPI quality assessment and performance improvement SN skilled nurse SOC start of care

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 coordination of care or communication with physicians were conducted prior to patient discharged from the agency for four (Patients #9, 11, 12 and 14) of 15 patients. Findings: Patient #9 A review of the clinical record showed the patient SOC was on 10/09/24 for SN and PT services. Documentation showed the patient was discharged from agency services at the time of PT discipline discharge on 11/05/24. Documentation showed no coordination of care or communication with the physician to discharge the patient from all agency services, showed no advance notice of discharge, and showed no documented reasons for the agency to discharge the patient for cause from agency services. Patient #11 A review of the clinical record showed the patient SOC was on 04/10/24 for OT and PT services. Documentation showed the patient was discharged from agency services at the time of OT discipline discharge on 05/06/24 (one week early) due to no insurance authorization. Documentation showed no coordination of care or communication with the physician to discharge the patient from all agency services, showed no advance notice of discharge, and showed no documented reasons for the agency to discharge the patient for cause from agency services. Patient #12 A review of the clinical record showed the patient SOC was on 06/03/24 for SN and PT services. Documentation showed the patient was transferred with discharged to in-patient hospital services on 06/27/24. Documentation showed no coordination of care or communication with the physician to discharge the patient from all agency services, showed no advance notice of discharge, and showed no documented reasons for the agency to discharge the patient for cause from agency services. Patient #14 A review of the clinical record showed the patient SOC was on 04/23/24 for SN and PT services. Documentation showed the patient was discharged for cause on 05/10/24 after declining a SN visit. Documentation showed no coordination of care or communication with the physician to discharge the patient from all agency services, showed no advance notice of discharge, and showed no documented reasons for the agency to discharge the patient for cause from agency services. On 11/07/24 at 12:15 p.m. to 12:50 p.m., Staff B stated patients #9, 11, 12 and #14: 1. Received no advance notice of discharge prior to discharge from agency services; and 2. Documentation showed no coordination of care or communication with the physician and showed no documented reasons for the agency to discharge the patients for cause prior to their discharge from agency services.

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 start of care within 48 hours of referral for one (Patient #7) of 15 patients. Findings: Patient #7 A review of the clinical record showed a referral date of 07/05/24 with a discharge from hospital services on 07/06/24 and a SOC date of 07/09/24 (3 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 11/07/24 at 11:30 a.m., Staff B stated documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders.

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. Speech Therapy and PEG feeding tube interventions and goals that were discontinued in the prior certification period for one (Patient #2) of 15 patients; 2. A last changed or intervention due date for urinary catheter management monthly catheter changes for two (Patients #5 and 6) of 15 patients; 3. PT intervention frequency and duration for one (Patient #8) of 15 patients and; 4. An intervention due date for reoccurring laboratory blood specimen collection for one (Patient #10) of 15 patients. Patient #2 A review of the POC dated 10/19/24 to 12/17/24 showed orders for SN two times a week for nine weeks for PEG feeding tube site care and ST to evaluate. Documentation showed the PEG feeding tube had been discontinued on 10/10/24 (5 days prior to the recertification period) and showed no ST evaluation. Documentation showed no physician notifications, and no changes in orders. On 11/07/24 at 10:00 a.m., Staff B stated the POC for patient #2 should not have included SN for PEG feeding tube site care or ST evaluation as both were discontinued in the prior recertification period. Patient #5 A review of the POC dated 10/11/24 to 12/19/24 showed orders for SN one time a week for nine weeks for SN to manage urinary catheter and change the catheter (24 French /10 cubic centimeter) every month. Documentation showed the last change date on the POC as 07/10/24 (prior certification period) and showed no catheter change due date for the current certification period. Documentation showed no physician notifications, and no changes in orders. On 11/07/24 at 10:45 a.m., Staff B stated the POC for patient #5 should have included a recent last change date on the POC and/or showed a catheter change due date for the current certification period. Patient #6 A review of the POC dated 09/21/24 to 11/19/24 showed orders for SN one time every four weeks for 10 weeks for SN to manage urinary catheter and change the catheter (16 French /10 cubic centimeter) every month. Documentation showed no last change date on the POC and showed no catheter change due date for the current certification period. Documentation showed no physician notifications, and no changes in orders. On 11/07/24 at 11:25 a.m., Staff B stated the POC for patient #6 should have included a recent last change date on the POC and/or showed a catheter change due date for the current certification period. Patient #8 A review of the POC dated 10/06/24 to 12/04/24 showed orders for SN two times a week for eight weeks, then one time a week for one week; CHHA two times a week for eight weeks, then one time a week for one week; and documentation showed PT interventions and goals but documented no frequency and duration. Documentation showed no physician notifications, and no changes in orders. On 11/07/24 at 11:45 a.m., Staff B stated the POC for patient #8 should have included a PT frequency and duration. Patient #10 A review of the POC dated 09/13/24 to 11/11/24 showed orders for SN one time a week for nine weeks for SN to conduct wound site care and assessment. Documentation showed orders for SN to obtain reoccurring laboratory blood specimen collection every three months via PICC line. Documentation showed no due date for the laboratory specimen collection. Documentation showed no physician notifications, and no changes in orders. On 11/07/24 at 12:35 a.m., Staff B stated the POC for patient #10 should have included a due date for the reoccurring laboratory blood specimen collection.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for two (Patients #7 and #8) of 15 patients. Findings: Patient #7 A plan of care dated 09/07/24 to 11/05/24 documented diagnoses of Diabetes Mellitus Type II with foot ulcer. Documentation showed orders for SN visit frequency of one time a week for nine weeks for SN to perform assessment and monitoring of blood sugar every visit. Documentation during SN visits dated 09/10/24, 09/24/24, 10/09/24, and on 10/15/24 showed no blood sugar readings. Documentation showed no physician provider notifications or coordination of care communications related to blood sugar readings and no changes in orders. On 11/06/24 at 11:25 a.m., Staff B stated the patient did not obtain a glucometer to monitor blood sugar for quite some time and documentation showed no physician notification the patient did not obtain a glucometer and showed no change in blood sugar monitoring by the SN. Patient #8 A plan of care dated 09/07/24 to 11/05/24 documented diagnoses of Hypertensive heart disease with heart failure. Documentation showed orders for SN visit frequency of two times a week for eight weeks for SN to perform assessment and monitoring of the patient’s weight report variances to the physician. Documentation during SN visits dated 10/10/24, 10/15/24, 10/18/24, 10/22/24, 10/29/24 and on 11/01/24 showed no weight readings as the patient was too heavy to weigh. Documentation showed no physician provider notifications or coordination of care communications related to the monitoring of the patient’s weight and no changes in orders. On 11/06/24 at 11:45 a.m., Staff B stated the patient was too heavy to weigh and documentation showed no physician notification the patient was unable to be weighted and showed no change in weight monitoring orders.

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 review of administrative QAPI records for calendar years 2023 and 01/01/24 to 11/06/24 showed no data collection sources or activities utilized in the analysis of data in the agency's QAPI Program. On 11/06/24 at 1:00 a.m., Staff A stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no program improvement data or analysis of collected data that showed improved quality of patient care for calendar year 2023 and 01/01/24 to 11/06/24.

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. 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 that included self-monitoring efforts (follow up) that identified and evaluated outcomes to improve care, services and operations for all patients and employees. Findings: A review of administrative QAPI records for calendar years 2023 and 01/01/24 to 11/05/24 showed no documentation of patient centered QAPI Program activities that included self-monitoring efforts (follow up) that identified and evaluated outcomes to improve care, services, and operations. On 11/06/24 at 1:00 p.m., Staff A stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no patient centered QAPI Program activities that included self-monitoring efforts (follow up) that identified and evaluated outcomes to improve care, services, and operations.

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: 1. SN to conduct urinary catheter change every month for one (Patient #5) of 15 patients; 2. SN to conduct assessment of patient blood sugar every visit and notify the physician of blood sugar less than 60 and greater than 300 for one (Patient #7) of 15 patients; 3. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for one (Patient #8) of 15 patients; 4. SN to conduct assessment of site and perform wound care every visit for one (Patient #10) of 15 patients; 5. SN to conduct blood specimen collection as ordered on the plan of care for one (Patient #10) of 15 patients. Findings: Patient #5 A review of the POC dated 10/11/24 to 12/19/24 showed orders for SN one time a week for nine weeks for SN to manage urinary catheter and change the catheter (24 French /10 cubic centimeter) every month. Documentation showed no catheter change during SN visits dated 10/03/24, 10/11/24, 10/15/24, 10/22/24, 10/29/24 and 11/05/24 (> 33 days). Documentation showed no patient refusal of care, no physician notifications, and no changes in orders. On 11/07/24 at 10:45 a.m., Staff B stated the documentation for patient #5 showed no every month catheter change from 10/03/24 to 11/05/24. Patient #7 A plan of care dated 09/07/24 to 11/05/24 documented diagnoses of Diabetes Mellitus Type II with foot ulcer. Documentation showed orders for SN visit frequency of one time a week for nine weeks for SN to perform assessment and monitoring of blood sugar every visit. Documentation during SN visits dated 09/10/24, 09/24/24, 10/09/24, and on 10/15/24 showed no blood sugar readings. Documentation showed no physician provider notifications or coordination of care communications related to blood sugar readings and no changes in orders. On 11/06/24 at 11:25 a.m., Staff B stated the patient did not obtain a glucometer to monitor blood sugar for quite some time and documentation showed no physician notification the patient did not obtain a glucometer and showed no change in orders for blood sugar monitoring. Patient #8 A plan of care dated 09/07/24 to 11/05/24 documented diagnoses of Hypertensive heart disease with heart failure. Documentation showed orders for SN visit frequency of two times a week for eight weeks for SN to perform assessment and monitoring of the patient’s weight and report variances to the physician. Documentation during SN visits dated 10/10/24, 10/15/24, 10/18/24, 10/22/24, 10/29/24 and on 11/01/24 showed no weight readings as the patient was too heavy to weigh. Documentation showed no physician provider notifications or coordination of care communications related to the monitoring of the patient’s weight and no changes in orders. On 11/06/24 at 11:45 a.m., Staff B stated the patient was too heavy to weigh and documentation showed no physician notification the patient was unable to be weighted and showed no change in weight monitoring orders. Patient #10 A review of the POC dated 09/13/24 to 11/11/24 showed orders for SN one time a week for nine weeks for SN to conduct wound site care and assessment. Documentation during SN visit dated 10/18/24 showed no wound site assessment or care was conducted by the SN. Documentation showed no patient refusal of care, no physician notifications, and no changes in orders. On 11/07/24 at 12:35 a.m., Staff B stated the SN should have conducted wound site assessment and care during the SN visit for patient #10.

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 all patients and employees. Findings: A review of administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar year 2023 and for 01/01/24 to 11/05/24. On 11/05/24 at 1:00 p.m., Staff A stated documentation showed no multi-disciplined skilled professional staff participation in ongoing QAPI program activities in calendar year 2023 and for 01/01/24 to 11/05/24 for the agency.

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 an agency program evaluation for calendar year 2023 and 01/01/24 to 11/05/24 for all patients and employees. Findings: A review of administrative records showed no governing body over-site and responsibility for the agency’s program evaluation for calendar year 2023 and 01/01/24 to 11/05/24. On 11/05/24 at 1:30 p.m., Staff A stated documentation showed no oversight of the agency’s program evaluation for calendar year 2023 and 01/01/24 to 11/05/24.

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/discharge summary was provided for three (Patients #1, 12 and #13) of 15 patients. Findings: Patient #1 A review of the clinical record documented transfer from the agency on 10/26/24 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. Patient #12 A review of the clinical record documented transfer from the agency on 06/10/24 to inpatient hospital provider services with subsequent discharge from agency services. Documentation showed no transfer/discharge summary was provided to the inpatient hospital service provider. Patient #13 A review of the clinical record documented transfer from the agency on 10/09/24 to inpatient hospital provider services with subsequent discharge from agency services. Documentation showed no transfer/discharge summary was provided to the inpatient hospital service provider. On 11/07/24 at 9:34 a.m. to 12:35 p.m., Staff B stated documentation showed no transfer/discharge summary was sent to the receiving service providers for patients #1, 12 and #13.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 10/25/21 to 10/26/21. 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 10/25/21 to 10/26/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B was identified as the contact person for administrative issues and Staff A was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff B, C and D and by phone with Staff A. The following condition level deficiency was cited as a result of the re-certification survey: 484.105 Organization and Administration of Services GLOSSARY: QAPI Quality Assessment and Performance Improvement

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 development of an individualized plan of care for seven (Patients #1, 2, 3, 5, 6, 11 and 12) of thirteen patients. Findings: Patient #1 A review of the plan of care dated 08/18/21 to 10/16/21 showed a primary diagnosis of infection of amputation (left lower extremity) with no patient specific pain goals or pain parameters to notify the physician. Patient #2 A review of the plan of care dated 10/05/21 to 12/03/21 showed a primary diagnosis of hypertensive heart with heart failure with no orders to obtain weights or weight parameters to notify the physician. Patient #3 A review of the plan of care dated 10/12/21 to 12/10/21 showed a primary diagnosis of failure to thrive in newborn with no orders to obtain vital signs or weights and no vital sign or weight parameters to notify the physician. Patient #5 A review of the plan of care dated 09/24/21 to 11/22/21 showed a primary diagnosis of cancer of the penis with no patient specific pain goals or parameters to notify the physician. Patient #6 A review of the plan of care dated 06/30/21 to 08/28/21 showed a primary diagnosis of cancer of the prostate with no patient specific pain goals or parameters to notify the physician. Patient #11 A review of the plan of care dated 09/25/21 to 11/23/21 showed a primary diagnosis of aftercare following joint replacement with no patient specific pain goals or parameters to notify the physician. Patient #12 A review of the plan of care dated 10/05/21 to 12/03/21 showed a primary diagnosis of aftercare following joint replacement with no patient specific pain goals or parameters to notify the physician. On 10/25/21 at 4:15 pm., Staff A stated the plans of care for Patients #1, 2, 3, 5, 6, 11 and 12 failed to be fully developed and individualized related to each patient's primary diagnosis.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body showed responsibility for the management and operation of the agency, developed a budget and provided oversight of the agency's Quality Assessment and Performance Improvement Program. This failed practice placed all employees and all 98 current patients at risk for poor management, oversight and at risk for unidentified health and safety issues in QAPI activities. (See G942) Based on record review and interview, the governing body failed to document the appointment of a qualified administrator responsible for day to day operations for all current patients and agency employees. This failed practice placed all employees and all 98 current patients at risk for poor management of services provided. (See 946) Based on record review and interview, the governing body failed to ensure professional direction was provided in the agency's daily functions. This failed practice placed all employees and all 98 current patients at risk of poor oversight of their health care needs. (See G948) Based on record review and interview, the governing body failed to ensure professional direction was provided to the agency. This failed practice placed all employees and 98 current patients at risk of inadequate care as a result of poor oversight. (See G988) .

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 the governing body showed responsibility for the management and operation of the agency, developed a budget and provided oversight of the agency's Quality Assessment and Performance Improvement Program. This failed practice placed all employees and all 98 current patients at risk for poor management, oversight and at risk for unidentified health and safety issues in QAPI activities. A review of agency records showed no governing body meeting minutes for 2019, 2020 and January 01, 2021 to October 26, 2021. On 10/26/21 at 11:00 am., Staff B stated there was no documentation of governing body meetings specific to the agency for 2019, 2020 and January 01, 2021 to October 26, 2021.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the governing body failed to document the appointment of a qualified administrator responsible for day to day operations for all current patients and agency employees. This failed practice placed all employees and all 98 current patients at risk for poor management of services provided. A review of agency records showed no governing body meeting minutes for 2019, 2020 and January 01, 2021 to October 26, 2021. On 10/26/21 at 11:00 am., Staff B stated there was no documentation of governing body meetings specific to the agency for 2019, 2020 and January 01, 2021 to October 26, 2021.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the governing body failed to ensure professional direction was provided in the agency's daily functions. This failed practice placed all employees and all 98 current patients at risk of poor oversight of their health care needs. A review of agency records showed no governing body meeting minutes for 2019, 2020 and January 01, 2021 to October 26, 2021. On 10/26/21 at 11:00 am., Staff B stated there was no documentation of governing body meetings specific to the agency for 2019, 2020 and January 01, 2021 to October 26, 2021.

Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to ensure professional direction was provided to the agency. This failed practice placed all employees and 98 current patients at risk of inadequate care as a result of poor oversight. A review of agency records showed no governing body meeting minutes for 2019, 2020 and January 01, 2021 to October 26, 2021. On 10/26/21 at 11:00 am., Staff B stated there was no documentation of governing body meetings specific to the agency for 2019, 2020 and January 01, 2021 to October 26, 2021.