Every finding on record at Comfort Care Home Health, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/03/23 to 10/04/23. Standard deficiencies were cited as a result of the Emergency Preparedness Program survey.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of administrative records showed no administrative processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency were in place. On 10/04/23 at 1:00 p.m., Staff A stated the agency did not have administrative processes for an integrated emergency preparedness response in place.

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 the staff contact information for the agency for all patients and staff. Findings: A review of administrative records showed no documentation the Emergency Preparedness Communication Plan included current staff contact information for the agency. On 10/04/23 at 1:00 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for current staff of the agency.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster drill / activation event conducted on 05/11/23 included staff participation for all patients and employees. Findings: A review of administrative records related to emergency preparedness drill / activation event conducted on 05/11/23 showed no staff participation or after action summary response. On 10/04/23 at 1:00 pm, Staff A stated an activation of the EP plan on 05/11/23 showed no staff participation or after action summary response.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/03/23 to 10/04/23. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative issues and Staff C was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A. Condition level deficiencies were cited in the following areas: 484.60 Care planning, Coordination of services, Quality of care 484.65 Quality Assessment and Performance Improvement 454.105 Organization and administration of services Glossary: ADLs activities of daily living CHHA certified home health aide CMS Center for Medicare Services EP Emergency Preparedness HHA Home Health Agency OSDH Oklahoma State Department of Health OT Occupational therapy PIP Performance Improvement Project PT Physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure patient forms for consent and acknowledgement of Patient Rights, billing, complaint and grievance processes were obtained and maintained in the patients clinical record for five (Patients #1, 2, 4, 5 and #7) of seven patients reviewed. Findings: On 10/03/23 at 9:45 a.m., Patient admission packet information that contained forms for consent, Patient Rights, billing, complaint and grievance processes and introduction to the agency were requested during the entrance conference of the survey. Documents were reviewed. Patient #1 Review of the clinical patient record showed a SOC date of 08/18/23. Documentation showed no electronic or paper attachments of consent or acknowledgment receipt of Patient Rights, billing, complaint and grievance processes forms. Patient #2 Review of the clinical patient record showed a SOC date of 06/02/23. Documentation showed no electronic or paper attachments of consent or acknowledgment receipt of Patient Rights, billing, complaint and grievance processes forms. Patient #4 Review of the clinical patient record showed a SOC date of 10/28/19. Documentation showed no electronic or paper attachments of consent or acknowledgment receipt of Patient Rights, billing, complaint and grievance processes forms. Patient #5 Review of the clinical patient record showed a SOC date of 07/12/23. Documentation showed no electronic or paper attachments of consent or acknowledgment receipt of Patient Rights, billing, complaint and grievance processes forms. Patient #7 Review of the clinical patient record showed a SOC date of 04/24/23. Documentation showed no electronic or paper attachments of consent or acknowledgment receipt of Patient Rights, billing, complaint and grievance processes forms. On 10/04/23 from 12:00 to 12:35 p.m., Staff C reviewed the clinical patient records and stated patients #1, 2, 4, 5 and #7: 1. Did not have consents or acknowledgement receipt of Patient Rights, billing, complaint and grievance processes forms documented in their clinical patient records and;. 2. Acknowledgement and consent form documentation for patients #1, 2, 4, 5 and #7 should have been obtained at start of care and then scanned into their electronic clinical records.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge oasis assessment was completed for one (Patient #5) of seven patients. Findings: Patient #5 A review of the clinical record showed a physical therapy discharge on 09/05/23. Documentation showed no discharge oasis assessment was scheduled or conducted. Documentation showed no communication to the physician the patient had completed services, no changes in orders and no discharge visit from the home health agency was completed. On 10/04/23 at 12:25 p.m., Staff C stated discharge oasis assessment had not been conducted for Patient #5.

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 (Patient's #6 and #7) of seven patients. Findings: Patient #6 A review of the clinical record showed the patient was transferred to inpatient services on 07/24/23. Documentation showed no transfer summary was completed and showed no documentation of communication or coordination of care with the receiving inpatient service provider. Patient #7 A review of the clinical record showed the patient was transferred to inpatient services on 06/12/23. Documentation showed no transfer summary was completed and showed no documentation of communication or coordination of care with the receiving inpatient service provider. On 10/04/23 at 12:30 p.m., Staff C stated the agency completed no transfer/discharge summary and had no inpatient follow up communication after the transfer to inpatient hospital services on Patients #6 and 7.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of an episodic Plan of Care after a recertification OASIS assessment for one (Patient #4) of seven patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve functional and physical health improvements for all patients. See Tag G572. Based on record review and interview, the agency failed to ensure an individualized patient POC included: 1. Wound care orders for one (Patient #1) of seven patients; 2. Goals related to primary diagnosis and SN interventions for disease management teaching/training and weekly FSBS for one (Patient #2) of eight patients and; 3. Goals related to pain management and SN interventions for disease management teaching/training and monitoring for one (Patient #6) of eight patients. The failed practice had the potential to effect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. See Tag G574. Based on record review and interview, the agency failed to ensure physician orders for changed wound site care were entered into the patient’s clinical record for one (Patient #7) of seven patients. The failed practice had the potential to effect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. See Tag G576. Based on record review and interview, the agency failed to ensure ongoing discharge planning and coordination of care for seven (Patients #1, 2, 3, 4, 5, 6 and 7) of seven patients. The failed practice had the potential to effect the provision of necessary home care services to achieve optimal patient care outcomes for all patients. See Tag G598. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of an episodic Plan of Care after a recertification OASIS assessment for one (Patient #4) of seven patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve functional and physical health improvements for all patients. Findings: Patient #4 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 08/08/23 to 10/06/23. Documentation showed no physician notification of the conducted recertification OASIS assessment on 08/04/23 and documented no physician communication or coordination of care. On 10/04/23 at 12:18 p.m., Staff C stated: Patient #4 did not have a POC (physician orders) for the episode period of 08/08/23 to 10/06/23; Had a reassessment OASIS visit on 08/04/23 but received no agency services after 05/22/23 SN visit and; Was not discharged from agency services.

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 an individualized patient POC included: 1. Wound care orders and goals related to SN intervention for wound site care and dressing changes for one (Patient #1) of seven patients; 2. Goals related to primary diagnosis and SN interventions for disease management teaching/training and weekly FSBS for one (Patient #2) of eight patients and; 3. Goals related to pain management and SN interventions for disease management teaching/training and monitoring for one (Patient #6) of eight patients. The failed practice had the potential to affect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. Findings: Patient #1 A review of a POC dated 08/18/23 to 10/16/23 showed a SN visit frequency of one time a week for seven weeks and then two times a week for one week and for SN to conduct wound site care and dressing changes. During SN visits conducted on 08/18/23, 08/23/23, 08/30/23, 09/06/23, 09/13/23, 09/20/23 and on 09/27/23 wound care was performed to wound sites identified as: lower abdomen, right side, left upper arm and midline back (wound sites were not consistently numbered from one SN visit to another); wound care to each site was documented as use of wound cleanser followed by application of an ABD dressing pad. Documentation showed no communications or coordination of care with the physician related to wound site care and dressing changes, wound site goals and showed no changes in orders. Patient #2 A review of a POC dated 08/01/23 to 09/29/23 showed a SN visit frequency of one time a week for seven weeks and then two times a week for one week and for SN to assess, conduct disease management teaching/training related to primary diagnosis of Diabetes Mellitus Type II and perform weekly FSBS for monitoring. Documentation showed no goals related to the primary diagnosis and SN interventions for disease management teaching/training and weekly FSBS monitoring. Documentation showed no communications or coordination of care with the physician related to goals for disease management teaching/training and FSBS monitoring and showed no changes in orders. Patient #6 A review of a POC dated 05/30/23 to 07/28/23 showed a SN visit frequency of one time a week for seven weeks and then two times a week for one week and for SN to assess, teaching/training for pain management and monitoring pain levels. Documentation showed no goals related to the SN interventions for pain management teaching/training and monitoring. Documentation showed no communications or coordination of care with the physician related to goals for pain management teaching/training, monitoring pain levels and showed no changes in orders. On 10/04/23 at from 12:00 p.m. to 12:30 p.m., Staff C stated: 1. The POC for patient #1 should have included wound site care orders and goals related to SN interventions for wound site care and dressing changes; 2. The POC for patient #2 should have included goals related to the patient’s primary diagnosis and SN interventions for disease management teaching/training and weekly FSBS monitoring and; The POC for patient #6 should have included goals related to pain management and SN interventions for disease management teaching/training and monitoring of pain levels.

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 physician orders for changed wound site care was entered into the patient’s clinical record for one (Patient #7) of seven patients. The failed practice had the potential to effect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. Findings: Patient #7 A review of a POC dated 04/24/23 to 06/22/23 showed a SN visit frequency of two times a week for eight weeks for SN to assess and perform wound site care to the left lower extremity with dressing changes consisting of: cleanse sites with normal saline, apply polymed pad (a type of dressing material) and secure with kerlex (a type of dressing material). A SN visit note dated 05/24/23 showed documentation of communication and coordination of care with the physician to change the wound site care to: cleanse with normal saline, apply medihoney (an anti-infective agent), cover with a polymed dressing and secure with a compression dressing three times a week. Documentation of SN visits on 05/26/23, 05/29/23, 05/31/23, 06/05/23, 06/07/23, 06/09/23 and on 06/12/23 showed the changed wound site care with dressing application. Documentation showed no entry of the physician orders obtained by the SN on 05/24/23. On 10/04/23 at 12:35 p.m., Staff C stated the SN did not enter the physician order for the change in the wound site care and dressing change materials that was obtained on 05/24/23.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure ongoing discharge planning and coordination of care for seven (Patients #1, 2, 3, 4, 5, 6 and 7) of seven patients. The failed practice had the potential to affect the provision of necessary home care services to achieve optimal patient care outcomes for all patients. Administrative records that showed ongoing discharge planning (case conferences) and coordination of care for Patients #1, 2, 3, 4, 5, 6 and 7 were requested. No records were provided. On 10/04/23 at 12:45 p.m., Staff C stated the agency nursing staff conducts discharge planning (case conferences) and coordination of care on all active patients every two weeks but case conferences are not documented anywhere.

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 patient centered QAPI Program for all patients and employees. The 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 all patients and employees. The 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 G644. Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees. The 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 the initiation and review of a PIP through their QAPI Program from 04/01/22 to 12/31/22 and 01/01/23 to 10/02/23 for all patients and employees. The 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 all patients and employees. The 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 patient centered QAPI Program for all patients and employees. The 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: Administrative records of ongoing patient centered QAPI program for the agency in calendar years 2021 and 2022 and 01/01/23 to 10/02/23 were requested. Documentation showed no QAPI program documentation for 2nd quarter, 3rd quarter or 4th quarter calendar year 2021; no QAPI program documentation for calendar year 2022; and no QAPI program documentation for 01/01/23 to 10/02/23. On 10/04/23 at 11:30 a.m., Staff B stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; There was no other evidence of an ongoing QAPI program to improve the care, services, and operations of the agency for 2nd quarter, 3rd quarter or 4th quarter calendar year 2021, calendar year 2022 and for 01/01/23 to 10/02/23.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The 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: Administrative records of ongoing patient centered QAPI program for the agency which showed data collection activities utilized in the agency's QAPI Program for calendar years 2021, 2022 and 01/01/23 to 10/02/23 were requested. Documentation showed no data collection sources or activities utilized in the agency's QAPI Program in calendar years 2021, 2022 and 01/01/23 to 10/02/23. On 10/04/23 at 11:30 a.m., Staff B stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; 2. Documentation showed no program improvement data and no analysis of collected data that showed improved quality of patient care for calendar years 2021, 2022 and 01/01/23 to 10/02/23.

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 all patients and employees. The 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: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of QAPI program activities to improve the care, services, and operations of the agency for calendar years 2021, 2022 and 01/01/23 to 10/02/23 were requested. Documentation showed no QAPI program activities for 2nd quarter, 3rd quarter or 4th quarter calendar year 2021; no QAPI program activities for calendar year 2022; and no QAPI program activities for 01/01/23 to 10/02/23. On 10/04/23 at 11:30 a.m., Staff B stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; 2. Documentation showed no program activities to improve the care, services, and operations of the agency for 2nd quarter, 3rd quarter or 4th quarter calendar year 2021, calendar year 2022 and for 01/01/23 to 10/02/23.

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 from 04/01/22 to 12/31/22 and 01/01/23 to 10/02/23 for all patients and employees. The 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: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of a QAPI program PIP for calendar years 2021, 2022 and 01/01/23 to 10/02/23 were requested. Documentation showed no PIP through the QAPI Program for the agency from 04/01/22 to 12/31/22 and 01/01/23 to 10/02/23. On 10/04/23 at 11:30 a.m., Staff B stated the agency had no QAPI PIP records for 04/01/22 to 12/31/22 and 01/01/23 to 10/02/23.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: Administrative records which showed governing body oversite of the conduction of patient centered QAPI Program activities for calendar years 2021, 2022 and 01/01/23 to 10/02/23 were requested. Documentation showed no governing body oversight of QAPI program activities for the agency for calendar years 2021, 2022 and 01/01/23 to 10/02/23. On 10/04/23 at 11:30 a.m., Staff B stated the agency had no QAPI records which showed governing body oversite of the conduction of the patient centered QAPI Program activities for calendar years 2021, 2022 and 01/01/23 to 10/02/23.

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 its infection control program included surveillance monitoring and reporting and was included in QAPI program activities for all patients and staff. Findings: Administrative records of an ongoing patient centered QAPI program for the agency which showed infection control program surveillance monitoring and reporting as a part of QAPI program activities for calendar years 2021, 2022 and 01/01/23 to 10/02/23 were requested. Documentation showed no infection control program surveillance monitoring and reporting as a part of QAPI program activities for calendar year 2021, 2022 and 01/01/23 to 10/02/23. On 10/04/23 at 11:30 a.m., Staff B stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; 2. Documentation showed no infection control program surveillance monitoring and reporting as a part of QAPI program activities for calendar years 2021, 2022 and 01/01/23 to 10/02/23.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the POC for: 1. SN to conduct visit frequencies as ordered by the physicians for two (Patients #2 and #3) of seven patients; 2. PT to conduct visit frequencies as ordered by the physicians for one (Patients #7) of seven patients; 3. OT to conduct visit frequencies as ordered by the physicians for one (Patients #7) of seven patients and; 4. CHHA to conduct visit frequencies as ordered by the physicians for two (Patients #4 and 7) of eight patients. Findings: Patient #2 A review of a POC dated 08/01/23 to 09/29/23 showed a SN visit frequency of one time a week for seven weeks and then two times a week for one week. Documentation showed during the week of 09/24/23 to 09/29/23 a SN visit was conducted on 09/26/23 (one visit conducted, two visits ordered). Documentation showed no patient/caregiver refusal of the visit, no physician notifications and no changes in orders. Patient #3 A review of a POC dated 07/23/23 to 09/20/23 showed a SN visit frequency of one time a week for nine weeks. Documentation showed during the week of 09/17/23 to 09/20/23 no SN visit was conducted (no visit conducted, one visit ordered). Documentation showed no patient/caregiver refusal of the visit, no physician notifications and no changes in orders. Patient #4 A review of the POC dated 08/08/23 to 10/06/23 showed documentation of a home health aide visits frequency of 6 hours a week or three times a week. Documentation showed no home health aide visits were conducted (no visits conducted, 24 visits ordered). Documentation showed no patient/caregiver refusal of the visit, no physician notifications and no changes in orders. Patient #7 A review of the POC dated 04/24/23 to 06/22/23 showed documentation of a home health aide visits frequency of 10 hours a week (number of visits was not documented), PT visits frequency of two times a week for four weeks and an OT visits frequency of one time a week for one week and then two times a week for three weeks. Documentation showed no home health aide visits (no visits [hours] conducted); no PT visits (no visits conducted, eight visits ordered) and no OT visits (no visits conducted, seven visits ordered). Documentation showed no patient/caregiver refusal of the visits, no physician notifications and no changes in orders. On 10/04/23 at 12:08 p.m. to 12:35 p.m., Staff C stated: SN visits should have been conducted as ordered by the physician for patients #2 and #3; PT visits should have been conducted as ordered by the physician for patient #7 OT visits should have been conducted as ordered by the physician for patient #7 and; 4. CHHA visits should have been conducted as ordered by the physician for patients #4 and 7.

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 staff participation in QAPI activities for calendar years 2021, 2022 and 01/01/23 to 10/02/23. On 10/04/23 at 11:30 a.m., Staff B stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; 2. Documentation showed no staff participation in QAPI activities for calendar years 2021, 2022 and 01/01/23 to 10/02/23.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the development of home health aide care plans for two (Patients #4 and 7) of seven patients. Findings: Patient #4 A review of the POC dated 08/08/23 to 10/06/23 showed a home health aide visits frequency of 6 hours a week or three times a week to provide/assist with personal care and assist with ADLs. Documentation showed no home health aide care plan and showed no coordination of care (staff assignment) between the RN staff and the CHHA staff. Patient #7 A review of the POC dated 04/24/23 to 06/22/23 showed a home health aide visits frequency of 10 hours a week (number of visits was not documented) to provide/assist with personal care and assist with ADLs. Documentation showed no home health aide care plan and showed no coordination of care (staff assignment) between the RN staff and the CHHA staff. On 10/04/23 at 12:18 p.m. to 12:35 p.m., Staff C stated home health aide care plans and the coordination of care (staff assignment) for patients #4 and 7 should have been documented in the clinical records.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of an operating budget, capital expenditure plan and agency program evaluation activities for calendar year 2021 and 1st quarter calendar year 2022 for all patients and staff. The failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. See Tag G942. Based on record review and interview, the agency failed to ensure governing body appointment of the clinical manager and/or supervising RN for the agency for all patients and staff. This failed practice had the potential to affect the care services provided by the agency impacting subsequent care outcomes of the patients and provide adequate clinical supervisory oversite of its staff. See tag G954. Based on record review and interview, the agency failed to ensure governing body appointment/designation of the alternate clinical manager/supervising RN for the agency for all patients and staff. This failed practice had the potential to affect the care services provided by the agency and the subsequent care outcomes of the patients; and provide adequate clinical supervisory oversite of its staff. See tag G958. Based on record review and interview, the agency failed to ensure the agency notified OSDH of its operating branch office for all patients and employees. The failed practice had the potential to affect the services provided by the agency in the communities that it serves and impact the professional licensure/certification integrity of the agency and its nursing service employees. See Tag G972. .

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 and allocation of an operating budget, capital expenditure plan and agency program evaluation activities for calendar year 2021 and 1st quarter calendar year 2022 for all patients and staff. The failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. Findings: Administrative records which showed governing body over-site and responsibility for the agency for calendar years 2021, 2022 and 01/01/23 through 10/02/23 was requested. Documentation showed no governing body oversite and allocation of an operating budget, capital expenditure plan and agency program evaluation activities for calendar year 2021 and 1st quarter calendar year 2022. On 10/04/23 at 11:30 a.m., Staff B stated: 1. All governing body documentation for the agency was provided in its entirety and; 2. Documentation showed no governing body oversite and allocation of an operating budget, capital expenditure plan and agency program evaluation activities for calendar year 2021 and 1st quarter calendar year 2022.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of the clinical manager and/or supervising RN for the agency for all patients and staff. This failed practice had the potential to affect the care services provided by the agency impacting subsequent care outcomes of the patients and provide adequate clinical supervisory oversite of its staff. Findings: A review of governing body records showed governing body designation of an employee (name withheld) different than the staff identified as the clinical manager/supervising RN (Staff C) for the agency. On 10/04/23 at 11:30 a.m., Staff B stated the agency had no administrative records which showed governing body appointment/designation of the clinical manager/Supervising RN (Staff C) for the agency.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment/designation of the alternate clinical manager/supervising RN for the agency for all patients and staff. The failed practice had the potential to effect the care services provided by the agency and the subsequent care outcomes of the patients; and provide adequate clinical supervisory oversite of its staff. Findings: A review of governing body records showed no governing body designation of an alternate clinical manager/supervising RN for the agency. On 10/04/23 at 11:30 a.m., Staff B stated the agency had no administrative records which showed governing body appointment/designation of the alternate clinical manager/Supervising RN for the agency.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency notified OSDH of its operating branch office for all patients and employees. The failed practice had the potential to affect the care and services provided by the agency in the communities that it serves and impact the professional licensure/certification integrity of the agency and its nursing service employees. Findings: On 10/03/23 at 9:25 a.m., agency entrance conference was conducted. Staff A stated the agency did not have a branch operation under its provider number. A review of administrative records showed documentation that 28 of 65 active patients (43%) were located more than 60 miles from the agency’s office location in and around the areas of Comanche, Duncan, Elgin, Lawton, Geronimo, Temple and Walters, Oklahoma. An administrative record titled active employee roster showed documentation of Staff I (name withheld) as a Branch Manager and identified five additional staff assigned to an unidentified branch location. On 10/04/23 at 8:23 a.m., Staff G stated she worked out of the agency’s Walters, Oklahoma office and was supervised by Staff I (Branch Manager) out of that location. At 8:31 a.m., Staff H (an RN) stated she worked out of the agency’s Walters, Oklahoma office and was supervised by Staff I (Branch Manager) out of that location. At 12:40 p.m., Staff C stated Staff I was the RN supervisor at the Walters, Oklahoma branch office of the agency. At 1:15 p.m., Staff A stated the agency would need to notify OSDH and CMS of the agency’s branch office at the Walters, Oklahoma location.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided for two (Patients #6 and #7) of seven patients. Findings: Patient #6 A review of the clinical record showed the patient was transferred to inpatient services on 07/24/23. Documentation showed no transfer summary and no summary of care was provided to the receiving inpatient service provider. Patient #7 A review of the clinical record showed the patient was transferred to inpatient services on 06/12/23. Documentation showed no transfer summary and no summary of care was provided to the receiving inpatient service provider. On 10/04/23 at 12:30 p.m., Staff C stated the agency did not provide a transfer/discharge summary to the hospital service provider, patient/caregiver or physician at the time of transfer/discharge from agency services for patients #6 and 7.