Every finding on record at Best Choice Home Health Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 02/04/25 to 02/05/25. 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) that identified a date the assessment was developed and implemented and/or was review for all patients and employees. Findings: A review of administrative records showed a community-based risk assessment which identified the agency but showed no date the assessment was developed and implemented and/or was review for the agency, its patient population, or its employees. On 02/05/25 at 12:50 p.m., Staff A stated the AHRA did not identify a date the assessment was developed, implemented and/or was reviewed for the agency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to current employee contact information for the agency, for all patients and employees. Findings: Administrative records showed no updated Emergency Preparedness Communication Plan which included current employee contact information for the agency. On 02/05/24 at 12:50 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for current employees of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency from 02/04/25 to 02/05/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as a contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the survey. Glossary: EMR electronic medical record HHA Home Health Agency HHCOC home health change of care PIP performance improvement project POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile was updated for ordered medications for one (Patient #5) of 13 patients. Findings: Patient #5 A review of a POC dated 12/04/24 to 02/01/25 showed a SN visit note dated 01/20/25 that documented the patient was taking an antibiotic for infection. The SN visit note did not identify the antibiotic or note a dosing regimen of the medication. Documentation showed no follow up review or update to the medication profile by the SN. Documentation showed no physician notifications, and no change in orders. On 02/05/25 at 1:19 p.m., Staff A stated documentation showed no follow up review or update to the medication profile by the SN.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a transfer/discharge summary for five (Patients #3, 10, 11, 12 and #13) of 13 patients. Findings: Patient #3 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/22/25. Documentation showed no transfer summary was completed. Patient #10 A review of the clinical record showed the patient was transferred with discharge to in-patient hospice care on 10/01/25. Documentation showed no transfer/discharge summary was completed. Patient #11 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/05/25. Documentation showed no transfer summary was completed. Patient #12 A review of the clinical record showed the patient was transferred to in-patient hospital care on 10/15/24. Documentation showed no transfer summary was completed. Patient #13 A review of the clinical record showed the patient was discharged from the agency on 08/05/24. Documentation showed no discharge summary was completed. On 02/05/25 at 1:14 p.m. to 1:50 p.m., Staff A stated the agency did not complete provide: 1. Transfer summaries for patients #3, 11, 10 and 12 and; 2. No discharge summary for patient #13.

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. SN intervention durations for two (Patients #2 and #3) of 13 patients. 2. SN intervention for assessment, instruction and interventions for wound management showed no identified wound care site or goals for one (Patient #3) of 13 patients. 3. SN intervention for assessment, instruction and management of Mickey button (gastrostomy feeding tube) change every three months did not identify a button (gastrostomy feeding tube) location, size, last changed or due date of intervention for one (Patients #4) of 13 patients. 4. SN intervention for assessment and instruction for management of weight showed no weight reporting parameters to report to the physician for one (Patient #5) of 13 patients. 5. SN intervention for assessment, instruction and interventions for venipuncture and laboratory monitoring of a health condition for one (Patient #6) of 13 patients. Findings: Patient #2 A review of the POC dated 12/29/24 to 02/26/25 showed orders for SN to assess and instruct the patients’ health conditions every visit. Documentation showed no duration of SN services showed no physician notifications and no change in orders. On 02/05/25 at 1:12 p.m., Staff A stated the POC documentation identified no duration of SN services. Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed orders for SN to assess and instruct the patients’ health conditions and perform wound site care every visit. Documentation showed no duration of SN services and no identified wound care site or goals. Documentation showed no physician notifications and no change in orders. On 02/05/25 at 1:14 p.m., Staff A stated the POC documentation identified no duration of SN services and did not identify wound care site or goals. Patient #4 A review of the POC dated 01/04/25 to 03/30/25 showed orders for SN to assess and instruct the patients’ health conditions and perform Mickey button (gastrostomy feeding tube) management with intervention to change the Mickey button every 3 months. Documentation did not identify a button (gastrostomy feeding tube) location, size, last changed or due date of intervention and showed no physician notifications and no change in orders. On 02/05/25 at 1:17 p.m., Staff A stated the POC documentation identified no button (gastrostomy feeding tube) location, size, last changed or due date of intervention. Patient #5 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN to assess and instruct the patient weight every visit. Documentation showed no weight reporting parameters to report to the physician and showed no physician notifications and no change in orders. On 02/05/25 at 1:19 p.m., Staff A stated the POC documentation identified no weight reporting parameters to report to the physician. Patient #6 A review of the POC dated 12/13/24 to 02/10/25 showed orders for SN to perform venipuncture and laboratory monitoring of a complete blood count and clozapine (a medication) every month. Documentation showed no last completed or next due date of the intervention. On 02/05/25 at 1:19 p.m., Staff A stated the POC documentation identified no last completed or next due date for the intervention.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physician order for SN to perform wound site care and management was a part of the patient’s plan of care for one (Patient #3) of 13 patients. Findings: Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed a physician’s order dated 01/13/25 attached to the clinical record for SN to perform wound site care and management two times a week but documented no location of the wound site. Documentation showed no physician notification and no changes in orders. On 02/05/25 at 1:14 p.m., Staff A stated the SN order for patient #3 showed no wound site location, no physician notifications and no changes in 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 quality indicator data from OASIS (patient assessment data) reporting 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 2024 showed no quality indicator data collection sources from OASIS (patient assessment data) reporting utilized in the analysis of data in the agency's QAPI Program. On 02/05/25 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 collection or analysis of quality indicator data from OASIS (patient assessment data) reporting for calendar years 2023 and 2024.

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 interviews, the agency failed to ensure the required performance improvement project documentation for the agency included measurable goals (threshold levels) to measure performance in calendar years 2023 and 2024.for all patients and employees. Findings: A review of QAPI Program documentation showed no required performance improvement project documentation for the agency included no measurable goals (threshold levels) to measure performance in calendar years 2023 and 2024. On 02/05/25 at 1:00 p.m., Staff A stated the agency had no QAPI PIP documentation which included measurable goals (threshold levels) to measure performance in calendar years 2023 and 2024.

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. SN conducted visits as ordered for six (Patients #1, 3, 7, 10, 11 and #12) of 13 patients. 2. SN monitored the patients’ weight every visit as ordered for one (Patient #5) of 13 patients. 3. SN reported a patient’s reported pain level every visit as ordered for one (Patient #7) of 13 patients. Findings: Patient #1 A review of the POC dated 01/15/25 to 03/15/25 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week for nine weeks. Documentation showed during the week of 01/15/25 to 01/18/25 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:10 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed orders for SN to assess, instruct and monitor patients’ health conditions with a SN frequency of two times a week. Documentation showed during the week of 12/14/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:14 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #5 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN frequency of two times a week for one week, then one time a week for eight weeks for SN to assess, instruct and monitor patients’ weight every visit. Documentation of SN visit notes dated 12/06/24, 12/09/24, 12/11/24, 12/16/24, 12/23/24, 01/09/24 and on 01/20/25 showed no weight monitoring as ordered. Documentation showed no patient or caregiver refusal of weight monitoring, no physician notification and no changes in orders. On 02/05/25 at 1:19 p.m., Staff A stated weight monitoring of the patient should have been conducted as ordered by the physician. Patient #7 A review of the POC dated 01/06/25 to 03/06/25 showed orders for SN frequency of one time a week for SN to assess, instruct and monitor patients’ pain level every visit and report reported pain levels greater than 6 of 10 to the physician. Documentation of SN visit notes dated 01/06/25 reported a pain level of 7, 01/14/24 reported a pain level of 7 and on 01/27/25 reported a pain level of 7. Documentation showed no physician notifications and no changes in orders. On 02/05/25 at 1:30 p.m., Staff A stated the SN should have notified the physician of the patient’s reported pain levels greater than 6 of 10 as ordered by the physician. Patient #10 A review of the POC dated 08/29/25 to 10/27/25 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week for nine weeks. Documentation showed during the week of 09/01/24 to 09/07/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:35 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #11 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week. Documentation showed during the week of 12/04/24 to 12/07/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:40 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician. Patient #12 A review of the POC dated 08/19/24 to 10/17/24 showed orders for SN to assess, instruct and monitor the patients’ health conditions with a SN frequency of one time a week. Documentation showed no during the week of 08/25/24 to 08/31/24 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/05/25 at 1:45 p.m., Staff A stated a SN visit should have been conducted as ordered by the physician.

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 years 2023 and 2024. On 02/05/25 at 1:00 p.m., Staff A stated documentation showed no evidence of multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit note documentation was completed for two (Patients #3 and #8) of 13 patients. Findings: Patient #3 A review of the POC dated 12/14/24 to 02/11/25 showed orders for SN to assess, instruct and monitor patients’ health conditions and perform wound site care each visit with a SN frequency of two times a week. SN visit notes dated 12/20/24 and 12/24/24 documented no wound site interventions performed during the visits and documented no patient response to the interventions. On 02/05/25 at 1:14 p.m., Staff A stated SN clinical visit notes for 12/20/24 and 12/24/24 documented no wound site interventions and no patient response to the interventions. Patient #8 A review of the POC dated 12/18/24 to 02/15/25 showed orders for SN to assess, instruct and monitor patients’ health conditions and perform wound site care each visit with a SN frequency of two times a week for nine weeks. SN visit notes dated 12/23/24, 12/26/24, 12/30/24, 01/06/25, 01/09/25, 01/20/25 and on 01/27/25 documented no wound site interventions performed during the visits and documented no patient response to the interventions. On 02/05/25 at 1:32 p.m., Staff A stated SN clinical visit notes for 12/23/24, 12/26/24, 12/30/24, 01/06/25, 01/09/25, 01/20/25 and on 01/27/25 documented no wound site interventions and no patient response to the interventions.

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 interviews, the agency failed to ensure completed transfer/discharge summaries were provided to receiving service providers for five (Patients #3, 10, 11, 12 and #13) of 13 patients. Findings: Patient #3 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/22/25. Documentation showed no transfer summary, and no in-patient follow up communication was provided to the in-patient hospital service provider or physician. Patient #10 A review of the clinical record showed the patient was transferred with discharge to in-patient hospice care on 10/01/25. Documentation showed no transfer/discharge summary, and no in-patient follow up communications were provided to the in-patient hospice service provider, patient/caregiver or physician. Patient #11 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/05/25. Documentation showed no transfer summary, and no in-patient follow up communication was provided to the in-patient hospital service provider or physician. Patient #12 A review of the clinical record showed the patient was transferred to in-patient hospital care on 10/15/24. Documentation showed no transfer summary, and no in-patient follow up communication was provided to the in-patient hospital service provider or physician. Patient #13 A review of the clinical record showed the patient was discharged from the agency on 08/05/24. Documentation showed no discharge summary, and no summary of care was provided to the patient/caregiver or physician. On 02/05/25 at 1:14 p.m. to 1:50 p.m., Staff A stated the agency did not provide: 1. Transfer summaries for patients #3, 11, 10 and 12 to the receiving service providers and; 2. No discharge summary to the patient/caregiver or physician at the time of discharge from agency services for patient #13.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/19/22 to 04/20/22. Standard 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), §485.625(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 all patients and employees. Findings: An agency policy titled, Hazard Vulnerability Analysis, stated a hazard vulnerability analysis shall be performed, documented and updated at least annually. A review of administrative records showed no documentation of a community-based risk assessment which addressed the agency, its patient population, or its employees. On 04/19/22 at 1:30 p.m., Staff A stated the agency had no emergency preparedness community-based risk assessment.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included required staff contact information for the agency potentially affecting all staff and patients. Findings: An agency policy titled, Communication Plan during an Emergency/Disaster, stated the home health agency’s communication plan shall [include] a list of staff members including their contact information. A review of administrative records showed no documentation of required Emergency Preparedness Communication Plan staff contact information for the agency. On 04/19/22 at 1:30 p.m., Staff A stated the Emergency Preparedness Communication Plan for the agency had no staff contact information.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure required documentation included an after action evaluation of the agency’s response to an emergency preparedness disaster occurrence in 02/2022 for 73 patients and all staff members. Findings: A review of administrative records related to emergency preparedness showed no documentation of an after action evaluation of the agency’s response to an emergency preparedness disaster occurrence in 02/2022. On 04/19/22 at 1:30 pm, Staff A stated the agency had no documentation of an after action evaluation of the agency’s response to the emergency preparedness disaster occurrence in 02/2022.

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), §485.625(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, 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 tabletop exercises and/or drills were conducted for calendar year 2020 and 2021 for 73 patients and staff members. Findings: A review of administrative records related to emergency preparedness showed no agency disaster tabletop exercises, drills or participation in a community-based drills for calendar year 2020 and 2021. On 04/19/22 at 1:30 p.m., Staff A stated the agency had no documentation of an emergency preparedness disaster tabletop exercise, drill or participation in a community-based drill for calendar years 2020 and 2021.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/19/22 through 04/20/22 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 administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A. As a result of the survey, condition level deficiencies were cited in the following area: 454.65 Quality Assessment Performance Improvement Glossary: PIP Performance Improvement Project POC Plan of Care QAPI Quality Assurance Performance Improvement SN Skilled Nurse

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile and subsequent POC was updated and reviewed with an ordered medication for one (Patient #4) of seven patients. Findings: Patient #4 A review of a POC dated 04/08/22 to 06/06/22 showed an order dated 03/07/22 for Depo injection every month. The documentation showed the medication was not added to the medication profile, reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy, did not include a dose or dose instruction and was not updated on the subsequent POC. On 04/19/22 at 1:15 p.m., Staff A stated the medication profile and POC for Patient #4 did not but should have: 1. been updated with the medication; 2. included the dose to be administered; 3. reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a transfer/discharge summary for two (Patients #6 and #7) of seven patients. Findings: An agency policy titled, "Discharge/Transfer Policy," stated all discharged (transferred) patients will have required information to ensure appropriate communication is provided to the physician and the receiving agency. Patient #6 A review of the clinical record showed the patient was transferred and subsequently discharged from the agency on 10/22/21 to in-patient hospital care services. Documentation showed no transfer/discharge summary was completed. Patient #7 A review of the clinical record showed the patient was transferred and subsequently discharged from the agency on 02/08/22 to in-patient hospital care services. Documentation showed no transfer/discharge summary was completed. On 04/19/22 at 1:25 p.m., Staff A stated the agency did not complete a transfer/discharge summary for Patients #6 and #7.

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 physician notification or document an occurrence of a patient fall with significant injury for one (Patient #7) of seven patients. Findings: Patient #7 A review of the clinical record documented the patient experienced a fall with significant injury, was transported by EMS to in-patient hospital care services, was admitted, underwent surgical corrective interventions to the hip/pelvis and was subsequently discharged from the agency on 02/08/22. Documentation showed no physician notification, changes in orders; nor occurrence reporting of the incidence. On 04/19/22 at 1:30 p.m., Staff A stated the agency did not document the fall occurrence or show documentation of physician notification the patient had been hospitalized and subsequently discharged from the agency.

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 the individualized patient POCs included: 1. Blood sugar reporting parameters and Dexcom blood sugar monitoring device change treatment due dates for one (Patient #2) of seven patients; 2. Feeding tube change due dates were documented for two (Patients #3 and #5) of seven patients and; 3. Weekly laboratory testing/monitoring and monthly medication injection administration were documented for one (Patient #4) of seven patients. Findings: Patient #2 A review of the plan of care dated 03/12/22 to 05/10/22 documented a principal diagnosis of Diabetes Mellitus Type I. Documentation showed no blood sugar reporting parameters or Dexcom blood sugar monitoring device change treatment frequency or due dates. Patient #3 A review of the plan of care dated 03/12/22 to 04/30/22 documented a principal diagnosis of gastrostomy with a secondary diagnosis of dysphagia. Documentation showed feeding tube change every 90 days but documented no change treatment due dates. Patient #4 A review of the plan of care dated 04/08/22 to 06/06/22 documented a principal diagnosis of bipolar disorder with features. Documentation showed no weekly laboratory testing, no monitoring, no treatment; and no monthly medication injection administration. Patient #5 A review of the plan of care dated 03/07/22 to 05/07/22 documented a principal diagnosis of gastrostomy with a secondary diagnosis of cerebral palsy. Documentation showed feeding tube change every 3 months but documented no change treatment due dates. On 04/19/22 at 1:15 p.m., Staff A stated: Blood sugar reporting parameters and Dexcom blood sugar monitoring device change treatment frequency and due dates should have been on the POC for patient #2 but was not;Recurring feeding tube change due dates for Patients #3 and #5 should have been documented on the POCs but was not and;Weekly laboratory testing and monitoring; and the monthly medication injection administration for Patient #4 should have been included on the POC but was not.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure evidence of a comprehensive patient centered QAPI Program for 73 patients and all employees. This failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See Tag G642. 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 73 patients and all employees. This failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See Tag 644. Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for 73 patients and all employees. This failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See Tag G646. Based on record review and interview, the agency failed to ensure PIP documentation which showed measurable progress achieved for 73 patients and all employees. This failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See Tag G658. Based on record review and interview the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for 73 patients and all employees. This failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. See Tag G660.

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 comprehensive patient centered QAPI Program for 73 patients and all employees. This failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: An agency policy titled, Quality Assessment and Performance Improvement program, stated the agency must implement, evaluate and maintain an agency wide data driven program; the governing body is responsible for ensuring the program reflects the organization and services [including] an analysis of services furnished to patients, a review of patient outcomes, complaints and incidents, infection control activities, effectiveness and safety of services provided, agency responses to complaints and incidents, determination that services have been provided as outlined in the service plans, analysis of patient survey data and through annual evaluation of the total operation. The QAPI committee must meet quarterly and report to the governing body at least annually. A review of administrative records showed no ongoing comprehensive patient centered QAPI program and no comprehensive QAPI data collected, monitored or evaluated by the agency for calendar years 2020 and 2021; and for 01/01/22 through 04/20/22. On 04/19/22 at 1:30 p.m., Staff A stated there was no documentation which showed a comprehensive QAPI program for calendar years 2020 and 2021; and for 01/01/22 through 04/20/22.

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 73 patients and all employees. This failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: An agency policy titled, Committee Responsibilities, stated the committee will identify and review aspects of care; develop indicators, criteria and thresholds; implement data collection activities and methodologies; and analyze and evaluate data from QAPI activities. A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for calendar years 2020 and 2021; and for 01/01/22 through 04/19/22. On 04/19/22 at 1:30 p.m., Staff A stated they had no documentation which showed the analysis of data collected to improve the quality of patient care for calendar years 2020 and 2021; and for 01/01/22 through 04/19/22.

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 73 patients and all employees. This failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: A review of administrative records showed no documentation of ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar years 2020 and 2021; and for 01/01/22 through 04/19/22. On 04/19/22 at 1:30 p.m., Staff A stated they had no QAPI documentation which showed QAPI program activities for calendar years 2020 and 2021; and for 01/01/22 through 04/19/22.

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 PIP documentation which showed measurable progress achieved for 73 patients and all employees. This failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: A review of QAPI record documentation showed no measurable progress achieved by PIPs for calendar year's 2020, 2021 and 01/01/22 through 04/19/22. On 04/19/22 at 1:30 p.m., Staff A stated the agency had no PIP documentation which showed measurable progress achieved for calendar year's 2020, 2021 and for 01/01/22 through 04/19/22.

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 73 patients and all employees. This failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: An agency policy titled, Evaluation of Findings and Improving Performance, stated the governing body will participate in evaluating information collected and improving the performance of the agency. A review of administrative records showed no governing body oversite of ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar years 2020, 2021, and 01/01/22 through 04/19/22. On 04/19/22 at 1:30 p.m., Staff A stated they had no documentation which showed governing body oversite of QAPI program activities for calendar years 2020, 2021, and 01/01/22 through 04/19/22.

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: 1. The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for 73 patients and; 2. The Infection Control Program was included in QAPI activities for 73 patients and all employees. Findings: An agency policy titled, Collection and Organization of Data, stated the agency will measure surveillance, prevention and control of infection. A review of administrative records showed no documentation of an ongoing infection control program for the agency or infection control surveillance data for calendar years 2020, 2021, and 01/01/22 through 04/19/22. On 04/19/22 at 1:30 p.m., Staff A stated: 1. The agency had no comprehensive infection surveillance program in place and; 2. No infection surveillance activities were reported through the agency's QAPI program for calendar years 2020, 2021, and 01/01/22 through 04/19/22.

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 SN: 1. visit was conducted as ordered by the physician for one (Patient #3) of seven patients and; 2. Feeding tube change treatment was completed timely for one (Patient #5) of seven patients. Findings: Patient #3 A review of the POC dated 03/02/22 to 04/30/22 documented a principal diagnosis of gastrostomy tube encounter and showed a physician order for SN visit frequency of one time a week for nine weeks. Documentation showed no SN visits were conducted during the week of 03/13/22 to 03/19/22 (one visit missed). Documentation showed no second SN visit was attempted/conducted during the week of service, no physician notification of the missed visit and no change in orders. Patient #5 A review of the POC dated 03/02/22 to 04/30/22 documented a principal diagnosis of gastrostomy tube encounter and showed a physician order for SN to change the feeding tube every 3 months. Documentation showed the feeding tube was changed on 11/23/21 and again on 03/02/22 (14 weeks after last change date). Documentation showed no patient/caregiver refusal, no physician notification of delayed treatment intervention and no change in orders. On 04/19/22 at 1:10 p.m., Staff A stated: Missed SN visit for Patient #3 should have been reported to the physician and; The SN should have performed a feeding tube change treatment within the every 3 month timeframe as ordered by the physician.

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 for 73 patients and all employees. Findings: A review of administrative records showed no governing body oversite for calendar year's 2020, 2021 and 01/01/22 to 04/19/22. On 04/19/22 at 1:30 p.m., Staff A stated there was no documentation which showed governing body oversight for the agency for calendar year's 2020, 2021 and 01/01/22 to 04/19/22.

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 agency failed to ensure governing body oversite of an operating budget, capital expenditure plan and allocation of resources activities for calendar year's 2020, 2021 and 01/01/22 through 04/19/22 got 73 patients and all employees. Findings: A review of administrative records showed no governing body oversite of an operating budget, capital expenditure plan and allocation of resource activities for calendar year's 2020, 2021 and 01/01/22 to 04/19/22. On 04/19/22 at 1:30 p.m., Staff A stated there was no documentation which showed governing body oversight for the agency for calendar year's 2020, 2021 and 01/01/22 through 04/19/22.