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 02/07/22 to 02/08/22. 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 02/07/22 to 02/08/22. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A, C and D were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, C and D. Deficiencies were cited as a result of the re-certification survey: GLOSSARY: QAPI Quality Assessment and Performance Improvement OASIS Outcome and Assessment Information Set

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 development of an individualized plan of care for one (Patient #1) of eleven patients. Patient #1 A review of the plan of care dated 12/13/21 to 02/10/22 showed a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure and documented a skilled nurse frequency of six visits per month for one month and six visits per month for two months. The plan of care documented no interventions to notify the physician of significant weight gain or weight loss in relation to the primary disease process and no orders to monitor weights during skilled nurse assessments. A review of the electronic medical record showed the following: A skilled nurse assessment dated 12/21/21 documented no patient weight. A skilled nurse assessment dated 12/23/21 documented no patient weight. A skilled nurse assessment dated 12/27/21 documented no patient weight. A skilled nurse assessment dated 12/30/21 documented no patient weight. A skilled nurse assessment dated 01/13/22 documented no patient weight. A skilled nurse assessment dated 01/19/22 documented no patient weight. A skilled nurse assessment dated 01/26/22 documented no patient weight. On 02/08/22 at 10:49 am., Staff A stated the plan of care for Patient #1 should have documented interventions to notify the physician of significant weight gain or weight loss and for patient's weight to be monitored in relation to the primary disease process.

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. A review of administrative records showed no OASIS data collection activities utilized in the agency's QAPI Program for calendar years of 2020 and 2021. On 02/08/22 at 12:40 pm, Staff A stated they had no analysis of OASIS data available that showed improved quality of patient care for 2020 and 2021.