Every finding on record at Baptist Village Retirement Communities of Oklahoma, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 10/11/21 to 10/12/21. 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 10/11/21 to 10/12/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B and by phone with Staff C. Deficiencies were cited as a result of the re-certification survey: GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects QAPI Quality Assessment and Performance Improvement OASIS Outcome and Assessment Information Set

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 future patients. Findings: A review of administrative records showed no OASIS data collection activities utilized in the agency's QAPI Program for calendar years of 2019, 2020 and from January 01, 2021 to October 12, 2021. On 10/12/21 at 2:40 pm, Staff B stated they had no analysis of OASIS data available that showed improved quality of patient care for 2019, 2020 and from January 01, 2021 to October 12, 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 for all future patients and employees. Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities, no patient record audits and no QAPI meetings to improve the care, services and operations of the agency for calendar years 2019, 2020 or for January 01, 2021 to October 12, 2021. On 10/12/21 at 2:40 pm, Staff B stated they had no documentation which showed governing body oversite of QAPI program activities for calendar years of 2019, 2020 or for January 01, 2021 to October 12, 2021.

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 oversight of the agency for 2019 and 2020 for all staff and patients during 2019 and 2020. This failed practice placed all employees and all future patients at risk for unidentified health and safety issues in QAPI activities. Findings: A review of governing body minutes for 2019 and 2020 showed no oversight of agency's function and programs. On 10/12/21 at 2:15 pm, Staff B stated there were no Governing body minutes to show oversight to the functions or actions of the agency for 2019 and 2020.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure qualified nurses were employed to provide care to future patients. Findings: A review of employee records showed no employment of qualified nursing staff to provide direct patient care to future agency patients. On 10/12/21 at 1:00 pm, Staff C stated there were no current patients and no field nurses to provide patient care; therefore the agency was unable to recruit new patients at this time. Staff B stated the agency had no qualified nurses to provide direct patient care since 09/03/21.