Every finding on record at Carter Healthcare of Southwest Oklahoma, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/14/24 to 05/16/24. 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 05/14/24 to 05/16/24. 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 clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A and by teleconference call Staffs G, H, I and J. Deficiencies were cited as a result of the re-certification survey. Glossary: POC Plan of Care SN Skilled Nurse/Nursing PT Physical Therapy PIP Performance Improvement Project

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: 1. the physician was notified of PT and SN missed visits for two (Patients #1 and 4) of nine patients; 2. SN frequencies were followed as ordered for two (Patient #4 and 6) of nine patients; 3. SN notified the physician of systolic blood pressure outside the ordered parameters for one (Patient #6) of nine patients; and 4. SN notified the physician of weight outside the ordered parameter for one (Patient #6) of nine patients. 1. Patient #1 A review of the POC dated 05/04/24 to 07/02/24 showed a PT frequency of one visit per month for one month. A review of the medical record showed a PT missed visit dated 05/08/24 which documented the reason as family refused. Documentation showed no notification was made to the physician of the missed visit. Patient #4 A review of the POC dated 04/24/24 to 06/22/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 05/02/24 which documented the reason as patient/family declined, and no other visits for the week of 04/28/24 to 05/04/24. Documentation showed no notification was made to the physician of the missed visit. 2. Patient #4 A review of the POC dated 04/24/24 to 06/22/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 05/02/24 which documented the reason as patient/family declined, and no other visits for the week of 04/28/24 to 05/04/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #6 A review of the POC dated 04/07/23 to 06/05/23 showed a SN frequency of one visit per week for eight weeks, effective 04/19/23. A further review of a physician’s order dated 05/12/23 showed a SN frequency of one visit every other week for three weeks. A review of the medical record showed no SN visits were made for the week of 05/28/23 to 06/03/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 3. Patient #6 A review of the POC dated 04/07/23 to 06/05/23 showed an order for the physician to be notified of systolic blood pressure less than 90. A review of SN visit dated 05/05/23 showed a systolic blood pressure result of 88. Documents showed no physician notification for systolic blood pressure result less than 90. 4. Patient #6 A review of the POC dated 04/07/23 to 06/05/23 showed an order for the physician to be notified of weight greater than 100 pounds. A review of SN visit dated 05/05/23 showed a weight of 105 pounds. Documents showed no physician notification for weight greater than 100 pounds. On 05/16/24 at 11:36 a.m., Staff A stated: 1. there was no documentation of physician notification of PT and SN missed visits for Patients #1 and 4; 2. the SN frequencies for Patients #4 and 6 were not met as ordered by the physician; 3. there was no documentation of physician notification of systolic blood pressure being out of parameters for Patient #6; and 4. there was no documentation of physician notification of weight being out of parameters for Patient #6.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for six patients and current employees. A review of the agency’s documentation showed no records of performance improvement projects implemented, in development, on-going or completed for calendar year 2023. On 05/16/24 at 11:40 a.m., Staff A stated the agency had no documentation which showed PIP activities for calendar year 2023.

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 a PT evaluation was conducted as ordered for one (Patient #3) of nine patients. A review of the POC dated 05/01/24 to 06/29/24 showed an order for PT to evaluate the week of 05/06/24. A review of the medical record showed no PT evaluation was conducted for the week of 05/05/24 to 05/11/24. Documentation showed no patient/caregiver refusal of services, no physician notification and no changes in the order. On 05/16/24 at 11:27 a.m., Staff A stated the PT evaluation for Patient #3 was not conducted 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 of an operating budget and allocation of resources for calendar year 2023 effecting six patients and all staff. A review of administrative records showed no governing body over-site of the operating budget and allocation of resources for the agency in calendar year 2023. On 05/16/24 at 11:40 a.m., Staff A stated there was no documentation of governing body discussion of the operating budget or resource allocation needs for the agency for calendar year 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/25/21 to 05/26/21. Standard level 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 dated community-based risk assessment (All Hazards Risk Assessment) which identified the agency and it's branch operations for 199 patients and all employees. Findings: A review of administrative records showed an undated community-based risk assessment which failed to identify the agency and it's branch operations. On 05/26/21 at 12:00 p.m., Staff A stated the agency had no emergency preparedness community-based risk assessment that was dated or identified the agency and it's branch operations.

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 an emergency preparedness disaster table top exercises and drills were conducted for calendar year 2019 for all patients and staff members. Findings: A review of administrative records related to emergency preparedness showed no agency disaster table top exercises, drills or participation in community based drills for calendar year 2019. Additional information was requested and yielded no reports. On 05/26/21 at 12:00 p.m., Staff A stated the agency had no documentation of emergency preparedness disaster table top exercises, drills or participation in community based drills for calendar year 2019.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 05/25/21 through 05/26/21. An entrance conference was conducted with Staff A, B, C, D and E. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical issues and Staff B was identified as a contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D and F. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: OT occupational therapy POC plan of care PIP performance improvement project QAPI quality assurance performance improvement SN skilled nurse

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure notice of non-coverage was provided prior to discharge from agency services for one (Patient #13) of four patients. Findings: Patient #13 A review of the clinical record showed no notice of non- coverage prior to discharge from the agency on 03/09/21. On 05/26/21 at 12:00 p.m., Staff A stated there was no notice of non-coverage for Patient #13 prior to being discharged from the agency on 03/09/21.

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 POC included pain management interventions and pain reporting ranges for three (Pt's #5, 6 and #7) of 13 patients. Findings: Patient #5 A review of the plan of care dated 04/10/21 to 06/08/21 documented a principal diagnosis of acute pain. POC orders were for SN to instruct on disease management for acute pain. The POC documented no interventions for pain management and no parameter of pain to report to the physician for further interventions. Patient #6 A review of the plan of care dated 04/16/21 to 06/14/21 documented a principal diagnosis of pleural effusion. POC orders were for SN to instruct on disease management for acute pain. The POC documented no interventions for pain management and no parameter of pain to report to the physician for further interventions. Patient #7 A review of the plan of care dated 04/01/21 to 05/30/21 documented a principal diagnosis of pleural effusion. POC orders were for SN to instruct on disease management for acute pain. The POC documented no interventions for pain management and no parameter of pain to report to the physician for further interventions. On 05/26/21 at 11:36 a.m., Staff A stated pain management interventions and pain reporting ranges for Pt's #5, 6 and #7 should have been documented in the POC's.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure evidence of a patient centered QAPI Program for 199 patients and all employees. Findings: A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency for calendar year 2020 and for 01/01/21 through 05/26/21. Additional information was requested and yielded no further reports. On 05/26/21 at 10:30 p.m., Staff F stated there was no documentation which showed a QAPI program for calendar year 2020 or for 01/01/21 through 05/26/21.

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 199 patients and all employees. Findings: A review of administrative records showed no data collection activities utilized in an agency QAPI Program for calendar year 2020 or for 01/01/21 through 05/26/21. Additional information was requested and yielded no further reports. On 05/26/21 at 10:40 a.m., Staff F stated: 1. They had no analysis of data collected available that showed improved quality of patient care and; 2. Program improvement data for calendar year 2020 or for 01/01/21 through 05/26/21 was available.

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 199 patients and all employees. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar year 2020 and for 01/01/21 through 05/26/21. Additional information was requested and yielded no further reports. On 05/26/21 at 11:30 a.m., Staff F stated they had no agency QAPI documentation which showed ongoing QAPI program activities for calendar year 2020 and 01/01/21 through 05/26/21.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 199 patients and all employees. Findings: A review of QAPI records showed no documentation of the initiation, review, data analysis, or status of PIPs in calendar years 2019, 2020 or for 01/01/21 through 05/26/21. Additional information was requested and yielded no further reports. On 05/26/21 at 10:40 a.m., Staff F stated the agency had no documentation which showed PIP activities for calendar years 2019, 2020 or for 01/01/21 through 05/26/21.

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 199 patients and all employees. Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities and no QAPI meetings to improve the care, services, and operations of the agency for calendar years 2019, 2020 and for 01/01/21 through 05/26/21. Additional documentation was requested and yielded no further reports. On 05/26/21 at 11:00 a.m., Staff F stated they had no documentation which showed governing body oversite of QAPI program activities for calendar years 2019, 2020 and for 01/01/21 through 05/26/21.

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 a comprehensive infection control program was conducted for 199 patients and all employees. Findings: A review of administrative records showed no comprehensive infection control program for the agency for calendar year 2020 and for 01/01/21 through 05/26/21. Additional infection control surveillance documentation was requested and yielded no further reports. On 05/26/21 at 10:40 a.m., Staff F stated no infection surveillance activities were reported through the agency's QAPI program for calendar year 2020 and for 01/01/21 through 05/26/21.

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 in the POC for: 1. notification of patient weight gain greater than 5 pounds or more in 1 week for two (Pt's #4 and #5) of 13 patients; 2. SN visit frequency for one (Patient #5) of 13 patients and; 3. Timely OT evaluation for one (Patient #7) of 13 patients. Findings: Patient #4 A review of the POC dated 04/11/21 to 06/09/21 showed orders for SN to instruct the patient/caregiver to weigh weekly and to report a weight gain greater than 5 pounds or more in 1 week. A review of skilled nurses notes showed a patient weight of 320 pounds during the nursing visit on 04/28/21 and a patient weight of 344 pounds (24 pound weight gain) during a nursing visit on 05/05/21. Documentation showed no physician notification of the 24 pound weight gain and no change in orders. Patient #5 A review of the POC dated 04/10/21 to 06/08/21 showed a SN frequency of one day one, one day one and then one time a week for eight weeks with orders to instruct the patient/caregiver to weigh weekly and to report patient weight gain greater than 5 pounds or more in 1 week. 1) A review of clinical documentation showed a SN visit was missed on 04/12/21, during the week 04/18/21 to 04/24/21 (one missed visit), during the week of 05/02/21 to 05/08/21 (one missed visit) and during the week of 05/16/21 to 05/22/21 (one missed visit) and; 2) during a SN visit on 04/28/21, the patient weighed 168 pounds and on 05/10/21 the nurse documented patient weighed 178 pounds (10 pound weight gain.) Documentation showed no physician notification of the 10 pound weight gain and no change in orders. Patient #7 A review of the POC dated 04/01/21 to 05/30/21 showed an OT frequency of one month one, between 04/01/21 and 05/01/21. A review of visit notes showed no OT evaluation completed until 05/03/21 (2 days past the ordered evaluation date range). Documentation showed no attempts to complete the OT evaluation within the ordered date range, no physician notification of refused or missed visit attempt and no change in orders. On 05/26/21 at 11:50 a.m., Staff A stated: 1. SN should have notified the physician of patient weight gains at the time of the SN visits on Pt's #4 and #5; 2. SN should have conducted SN visits as ordered and notified the physician of SN missed visits for Patient #5 and; 3. The OT evaluation for Patient #7 should have been completed within the ordered date range of 04/01/21 through 05/01/21.

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: 1. patient centered QAPI Program and; 2. operating budget and allocation of resources for calendar years 2019 and 2020 effecting 199 patients and all staff. Findings: A review of administrative records showed no: 1) governing body oversite of an ongoing patient centered QAPI program; 2) QAPI program activities for calendar years 2019 and 2020; 3) governing body over-site of the operating budget and allocation of resources for the agency in calendar years 2019 and 2020. On 05/26/21 at 11:00 a.m., Staff F stated there was no documentation which showed evidence of: 1. governing body oversite of the agency's QAPI program and QAPI program activities for calendar years 2019 and 2020 and; 2. governing body discussion of the operating budget or resource allocation needs for the agency for calendar years 2019 and 2020.

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 discharge summary was provided for four (Pt's #10, 11, 12 and #13) of four patients. Findings: Patient #10 A review of the clinical record showed the patient was discharged from the agency on 01/05/21 to care of self. Documentation showed no discharge summary was completed or provided to the patient. Patient #11 A review of the clinical record showed the patient was discharged from the agency on 03/31/21 to hospice services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #12 A review of the clinical record showed the patient was discharged from the agency on 02/17/21 to in-patient hospital services. Documentation showed a transfer/discharge summary was completed on 02/26/21 (nine days after the transfer/discharge.) Documentation showed no transfer/discharge summary was provided to the patient or to the in-patient hospital service provider. Patient #13 A review of the clinical record showed the patient was discharged from the agency on 05/12/21 to care of self. Documentation showed no discharge summary was completed or provided to the patient. On 05/26/21 at 12:00 p.m., Staff A stated no transfer/discharge summaries were provided to the patients or to the receiving service providers for Pt's #10, 11, 12 and #13.