Every finding on record at Divine Care Home Health Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/07/26 to 04/09/26. No deficiencies were cited as a result of the Emergency Preparedness Program.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/07/26 to 04/09/26. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. As a result of the survey a standard level deficiency was cited.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the requested patient roster was updated for eight (Pt #8, 9, 10, 11, 12, 13, 14, and 15) of fifteen patients. Findings: On 04/07/26 at 1:45 pm a current patient census roster was requested. A review of the roster contained the names of patients #1-7 only and did not contain the names of patients 8 -15. Previously the patient census was reported to be 13. A corrected census report was requested which was not provided. On 04/08/26 at 10:15 am all clinical records for all current patients were requested. The clinical records for 15 current patients were received. On 04/07/26 at 3:20 pm, Staff A stated she had provided the surveyor with what she was able to do.

The Oklahoma State Department of Health attempted an unannounced Emergency Preparedness survey at the agency on 04/11/23. A pre-survey review of OSDH records showed the agency's license to operate a home care agency expires on 07/31/23. On 04/11/23 at 9:15 a.m. Observation of the site showed door signage that documented the agency operating hours as Monday through Friday, 9 a.m. to 5 p.m. A sign with the contact number of record for the agency and a secondary contact number (telephone number withheld [originated in Grand Prairie, Texas]). There was no answer to repeated knocks upon the door, no lights were on and shining through the window blinds. Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. At 9:53 a.m., Telephone contact was attempted to the telephone number provided to OSDH (contact number of record). The telephone could be heard ringing on the outside of the office door. The voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. A voice mail message was left informing the agency: the OSDH was onsite attempting to enter the agency for survey purposes there was no personnel onsite at the agency and tequested the agency to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. At 10:00 a.m., 3rd telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call. A voice mail message was left informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left, No personnel were onsite at the agency and neither call was returned by the home health agency personnel. At 10:08 a.m., The surveyor contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site and no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage. OSDH survey manager attempted to contact at the email of record for the designated agency administrator with no response from agency personnel. At 10:20 a.m., the 4th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:00 a.m., no personnel for the agency were onsite at the agency and no agency personnel had responded to telephone call or email contact attempts. At 11:06 a.m., 5th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:22 a.m., the surveyor ontacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey and that no agency staff had shown up or returned multiple phone calls. At 11:27 a.m., OSDH central office contacted CMS office to inform of no agency response and iniability to survey because no staff was available and the agency office was closed. At 11:45 a.m., OSDH surveyor remained onsite outside of the agency from 9:15 a.m. to 11:45 a.m. No agency personnel arrived at the agency and all contact attempts to the agency were unanswered. The Oklahoma State Department of Health conducted a second unannounced Medicare Emergency Preparedness Program survey at the agency on 04/12/23. Deficiencies were cited as a result of the Emergency Preparedness program survey.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development and implementation of an agency emergency preparedness program for all patients and employees Emergency Preparedness program administrative records for the agency were requested. No Emergency Preparedness program a records were provided. At 1:30 p.m., a second request to Staff A for Emergency Preparedness program administrative records for the agency yielded no results. On 04/12/23 at 3:45 p.m., Staff A stated the agency had not provided administrative records for the agency’s Emergency Preparedness program.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: 0006 EP RA Based on record review and interview, the agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for all patients and employees. Emergency Preparedness program records that showed a community-based risk assessment was requested. No Emergency Preparedness program administrative records were provided. At 1:30 p.m., a second request to Staff A for Emergency Preparedness program administrative records for the agency yielded no results. On 04/12/23 at 3:45 p.m., Staff A stated the agency had not provided records for the agency’s Emergency Preparedness program.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure administrative policies and procedures related to an Emergency Preparedness Plan were in place for all patients and employees. Emergency Preparedness program for policies and procedures related to an Emergency Preparedness Plan for the agency were requested. No Emergency Preparedness program administrative records were provided. At 1:30 p.m., a second request to Staff A for Emergency Preparedness program administrative records for the agency yielded no results. On 04/12/23 at 3:45 p.m., Staff A stated the agency had not provided records for the agency’s Emergency Preparedness program.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all patients and employees for all patients and employees Findings: Emergency Preparedness program records for the agency were requested. No Emergency Preparedness program administrative records were provided. At 1:30 p.m., a second request to Staff A for Emergency Preparedness program administrative records for the agency yielded no results. On 04/12/23 at 3:45 p.m., Staff A stated the agency had not provided records for the agency’s Emergency Preparedness program.

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 table-top exercises, drills, community drills or plan activation events were conducted for calendar years 2021 and 2022 for all patients and employees. Emergency Preparedness program records for the agency were requested. No Emergency Preparedness program administrative records were provided. At 1:30 p.m., a second request to Staff A for Emergency Preparedness program records yielded no results. On 04/12/23 at 3:45 p.m., Staff A stated the agency had not provided administrative records for the agency’s Emergency Preparedness program.

The Oklahoma State Department of Health attempted an unannounced Medicare re-certification survey at the agency on 04/11/23. A pre-survey review of OSDH records showed the agency's license to operate a home care agency expires on 07/31/23. On 04/11/23 at 9:15 a.m. Observation of the site showed door signage that documented the agency operating hours as Monday through Friday, 9 a.m. to 5 p.m. A sign with the contact number of record for the agency and a secondary contact number (telephone number withheld [originated in Grand Prairie, Texas]). There was no answer to repeated knocks upon the door, no lights were on and shining through the window blinds. Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. At 9:53 a.m., Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes, no personnel were onsite at the agency and requested the agency to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. At 10:00 a.m., 3rd telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left, requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 10:08 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site and no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage. OSDH attempted to contact at the email of record for the designated agency administrator. At 10:20 a.m., 4th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:00 a.m., no personnel for the agency were onsite at the agency and no agency personnel had responded to telephone call or email contact attempts. At 11:06 a.m., 5th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:22 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site, no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage and OSDH attempt to contact at the email of record for the designated agency administrator had no response. At 11:27 a.m., OSDH central office contacted CMS regional office to inform of no agency response to contact attempts by OSDH surveyor. At 11:45 a.m., OSDH surveyor remained onsite outside of the agency from 9:15 a.m. to 11:45 a.m. No agency personnel had arrived at the agency and all contact attempts to the agency had gone unanswered. The survey could not be completed due to the lack of available staff and a closed office. The Oklahoma State Department of Health conducted a second attempt for an unannounced Medicare re-certification survey in conjunction with a complaint (49763) survey at the agency on 04/12/23. At 9:00 a.m., surveyor arrived at the agency. No answer to multiple knocks on the door and the interior office lights were off. The posted office hours on the sign outside of the door were Monday thru Friday 9 a.m. to 5 p.m. At 9:02 a.m., attempted telephone call to the agency’s telephone number of record (also posted on the outside of the door), telephone was heard ringing inside of the office and then forwarded to a voice mail message identified as the secondary telephone number (number withheld, [location identified as Grand Prairie, Texas] also posted on the outside of the door). A voice mail message was left of attempted survey contact with a request to return the telephone call. At 9:05 a.m., a second telephone call was made to the secondary telephone number (number withheld location identified as Grand Prairie, Texas) posted on the outside of the door. Staff A (administrator) answered the telephone call and confirmed her identity. Staff A was informed OSDH was onsite at the agency for a second attempt to conduct an unannounced Medicare re-certification follow up survey in conjunction with a complaint survey. Staff A stated she was not at the office because she was at an appointment in Ardmore, Ok. an hour’s drive away from the office location. Staff A stated did not feel well and had tested positive for COVID on a home test last week and was experiencing a cough (denied being officially tested or diagnosed with COVID). Staff A stated the agency had a gas or carbon monoxide leak in the office on Monday and had to leave the office (denied being evacuated from the office and denied the building had been evacuated for a gas or carbon monoxide leak). Staff A was advised a designated alternate was required to be available in the administrator's absence. Staff A stated she was the administrator and clinical manager/supervising RN for the agency, had no alternate to act on her behalf for the agency and had no office manager/staff to facilitate survey entrance. At 10:18 a.m., Staff A contacted the surveyor by telephone and stated she was still at least a 30 minutes’ drive away from arriving at the agency. At 10:50 a.m., an entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. Survey related access to administrative records and clinical records was requested. Findings were discussed during an informal exit conference with Staff A. Condition level deficiencies were cited in the following areas: 484.50 Patient rights 484.55 Comprehensive assessment of patients 484.60 Care planning, Coordination of services, Quality of care 484.65 Quality Assessment and Performance Improvement 484.70 Infection prevention 484.75 Skilled professional services 454.105 Organization and administration of services 484.110 Clinical records Glossary: CHHA certified home health aide eMR electronic medical record EP Emergency Preparedness HHA Home Health Agency OT Occupational therapy PIP Performance Improvement Project PT Physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received a statement of rights at the time of admission to the agency for care and services for three (Patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of their rights and responsibilities prior to the provision of care and services by the agency. See tag G412. Based on record review and interview, the agency failed to ensure patients received the contact information for the agency’s administrator at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of the contact information of the agency’s administrator for complaints related to the provision of care and services by the agency and its personnel. See tag G414. Based on record review and interview, the agency failed to ensure patients received the notice of discharge and transfer policies for the agency at the time of admission to the agency for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of discharge and transfer policies for the agency. See tag G422. Based on record review and interview, the agency failed to ensure patients received informed consent at the time of admission to the agency for care and services for three (Patients #2, 7 and #8) of eight patients. The failed practice violated the patient rights to be informed, have a comprehensive assessment completed and to participate in the planning of their services and care. See tag G434. Based on record review and interview, the agency failed to ensure patients received informed notice of their right to a complete clinical record and the right to have protected health information for three (Patients #2, 7 and #8) of eight patients. The failed practice violated the patient rights to a complete clinical record and have protected health information. See tag G438. Based on record review and interview, the agency failed to ensure patients received a statement of billing and complaint processes at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of service charges, billing, and complaint processes prior to the provision of care and services. See tag G440. Based on record review and interview, the agency failed to ensure patients received a statement of the grievance processes and OSDH complaint hotline information at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of grievance processes for the agency and OSDH complaint hotline information prior to the provision of care and services. See tag G444. Based on record review and interview, the agency failed to ensure the receipt and subsequent investigation and documentation of related actions of patient complaint, incidence and grievance for all patients and employees. The failed practice had the potential to effect the patients’ right to complaint, incidence and grievance processes for the agency related to the provision of care and services provided by the agency. See tag G478. .

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received a statement of rights at the time of admission to the agency for care and services for three (Patients #2, 7 and 8) of eight patients. The failed practice denied the patients their right to be informed of their rights and responsibilities prior to the provision of care and services by the agency. Patient #2 A review of administrative records showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No additional documentation was shown or provided. Patient #7 A review of administrative records showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. Patient #8 A review of administrative records showed a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. On 04/12/23 at 10:50 a.m., Patient admission packet information that contained forms for Patient Rights and introduction to the agency and access to all clinical records for current patients and all discharged patients in the last year were requested. The requested information was not provided. At 1:30 p.m., a second request for patient admission information, patient forms, and access to all clinical records for current patients and all discharged patients in the last year were requested. The requested information was not provided. At 2:20 p.m., limited access to patient clinical records was granted. No clinical record access was granted for patients #2, 7 and #8 and no requested or additional information was provided. At 3:40 p.m., Staff A stated the requested information was unavailable.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received the contact information for the agency’s administrator at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of the contact information of the agency’s administrator for complaints related to the provision of care and services by the agency and its personnel. Based on record review and interview, the agency failed to ensure patients received the contact information for the agency’s administrator at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of the contact information of the agency’s administrator for complaints related to the provision of care and services by the agency and its personnel. See tag G414. Findings: Patient #2 A review of administrative records showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No other documentation was shown or provided. Patient #7 Administrative records show a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. Patient #8 Administrative records show a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. On 04/12/23 at 10:50 a.m., patient admission packet information that contained forms and contact information for the agency’s administrator to receive complaints, access to all clinical records for current patients and all discharged patients in the last year were requested during the entrance conference of the survey. No information or copy of the Patient admission packet and other requested forms were provided. At 1:30 p.m., a second request for patient admission, access to all clinical records for current patients and all discharged patients in the last year were requested. No information or copy of the requested forms were provided. At 2:20 p.m., limited access to patient clinical records (eMRs) was granted. A review of the eMR’s were completed for patients # 1, 3, 4, 5 and #6. No clinical record access was granted for patients #2, 7 and #8. No documented paper or electronic forms for receipt of contact information for the agency’s administrator to receive complaints for patients #2, 7 and #8 was available or provided. At 3:40 p.m., Staff A was informed that due to requested patient and administrative records, the survey was being concluded. ision of care and services to the patients at the time of survey. At 3:50 p.m., the survey was concluded and the informal exit conference was conducted.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received the notice of discharge and transfer policies for the agency at the time of admission to the agency for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of discharge and transfer policies for the agency Patient #2 A review of administrative records showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No other documentation was shown or provided. Patient #7 A review of administrative records showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. No additional documentation was shown or available. Patient #8 A review of administrative records showed a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. No additional documentation was shown or available. On 04/12/23 at 10:50 a.m., Patient admission packet information that contained discharge and transfer policies for the agency and access to all clinical records for current patients and all discharged patients in the last year were requested. No Patient admission packet or other requested documentation was provided. At 1:30 p.m., a second request for patient admission packet information with patient forms and access to all clinical records for current patients and all discharged patients in the last year were requested. No additional documentation was provided. At 2:20 p.m., limited access to patient clinical records (eMRs) was granted. No documented paper or electronic forms for consent, receipt of discharge and transfer policies for the agency or clinical records were provided for patients #2, 7 and #8. At 3:40 p.m., Staff A stated requested records and documentation was unavailable.

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 patients received informed consent at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice violated the patient rights to be informed, have a comprehensive assessment completed and to participate in the planning of their services and care. Patient #2 A review of administrative records showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No other documentation was provided. Patient #7 A review of administrative records showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. No other documentation was provided. Patient #8 Administrative records show a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. No other documentation was provided On 04/12/23 at 10:50 a.m., Patient admission packet information that contained forms for consent and introduction to the agency; and access to all clinical records for current patients and all discharged patients in the last year were requested. No information or copy of the Patient admission packet and other requested forms were provided. At 3:40 p.m., Staff A stated the requested information was not available.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received informed notice of their right to a complete clinical record and the right to have protected health information for three (Patients #2, 7 and #8) of eight patients. The failed practice violated the patient rights to a complete clinical record and have protected health information. Patient #2 A review of administrative records showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No other documentation was provided. Patient #7 A review of administrative records showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. No other documentation was provided. Patient #8 Administrative records show a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. No other documentation was provided On 04/12/23 at 10:50 a.m., Patient admission packet information that contained forms for consent and introduction to the agency; and access to all clinical records for current patients and all discharged patients in the last year were requested. No information or copy of the Patient admission packet and other requested forms were provided. At 3:40 p.m., Staff A stated the requested information was not available.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received a statement of billing and complaint processes at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of service charges, billing, and complaint processes prior to the provision of care and services. Patient #2 A review of administrative records showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No other documentation was provided. Patient #7 A review of administrative records showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. No other documentation was provided. Patient #8 Administrative records show a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. No other documentation was provided On 04/12/23 at 10:50 a.m., Patient admission packet information that contained forms for consent and introduction to the agency; and access to all clinical records for current patients and all discharged patients in the last year were requested. No information or copy of the Patient admission packet and other requested forms were provided. At 3:40 p.m., Staff A stated the requested information was not available.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received a statement of the grievance processes and OSDH complaint hotline information at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of grievance processes for the agency and OSDH complaint hotline information prior to the provision of care and services. Patient #2 A review of administrative records showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No other documentation was provided. Patient #7 A review of administrative records showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. No other documentation was provided. Patient #8 Administrative records show a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. No other documentation was provided On 04/12/23 at 10:50 a.m., Patient admission packet information that contained forms for consent and introduction to the agency; and access to all clinical records for current patients and all discharged patients in the last year were requested. No information or copy of the Patient admission packet and other requested forms were provided. At 3:40 p.m., Staff A stated the requested information was not available.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the receipt and subsequent investigation and documentation of related actions of patient complaint, incidence and grievance for all patients and employees. The failed practice had the potential to effect the patients’ right to complaint, incidence and grievance processes for the agency related to the provision of care and services provided by the agency. On 04/10/23 OSDH conducted off-site survey preparation activities for pending agency survey, to include investigation of complaint #49763. On 04/11/23 at 9:15 a.m. to 11:45 a.m., OSDH attempted survey at the agency. No agency personnel were onsite at the agency. Multiple telephone and an email attempts to contact the agency and the agency’s administrator were not responded to. On 04/12/23 at 10:50 a.m., survey entrance conference for second attempt of survey at the agency was conducted. The agency was informed investigation of complaint #49763 would coincide with the agency survey. Administrative records related to complaints, incidents and grievances for the agency in calendar years 2021 and 2022 were requested; and access to all clinical records for current patients and all discharged patients in the last year were requested during the entrance conference of the survey. No requested documentation was provided. At 1:30 p.m., a second request for administrative records related complaints, incidents and grievances for the agency in calendar years 2021 and 2022; and access to all clinical records for current patients and all discharged patients in the last year were requested. The requested complaint documentation was not provided. At 3:40 p.m., Staff A stated the requested documentation was unavailable. There was no complaint documentation related to receipt/investigation/conclusion of complaints provided or available.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a resumption of care (updated comprehensive assessment was completed for one (Patient #4) of eight patients. The failed practice had the potential to impact the patient’s health care needs and outcomes. See Tag G544. Based on record review and interview the agency failed to ensure a recertification (updated comprehensive) assessment was completed for one (Patient #2) of eight patients. The failed practice had the potential to impact the care and services required to meet the continuing health care needs for all patients. See tag G546. .

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a recertification assessment was completed for one (Patient #2) of eight patients. The failed practice had the potential to impact the care and services required to meet the continuing health care needs for all patients. Patient #2 A request for clinical records yielded an administrative record which showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. Requested documentation was not provided. On 04/12/23 at 10:50 a.m., access to all clinical records for current patients was requested. At 1:30 p.m., a second request for access to all clinical records for current patients was requested. At 3:35 p.m., Staff A stated that clinical records for patient #2 were not available.

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 two (Patients #7 and #8) of eight patients. Patient #7 A request for clinical records yielded an administrative record which showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22. Documentation showed no agency discharge date and the clinical record was not provided. At 11:45 a.m., Staff A stated patient #7 was listed as an active patient on the active patient roster and had been discharged from the agency. At 11:58 a.m., Staff A stated patient #7 was not listed as a discharged patient for the agency on the agency discharge roster for the last year and the date of discharge from the agency was not known. At 1:30 p.m., a second request for access to all clinical records was made. At 3:35 p.m., Staff A stated that clinical records were not available for Patientt# 7. Patient #8 A request for the clinical record yielded an administrative record which showed a SOC date of 10/21/22 and an episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date and the clinical record was not provided. At 11:45 a.m., Staff A stated patient #8 was listed as an active patient on the active patient roster, had been referred (referral unknown) but was not admitted to the agency, and was discharged in the eMR system. At 11:58 a.m., Staff A stated patient #8 was not listed as a discharged patient for the agency on the agency discharge roster for the last year and the date of non-admit to the agency was not known. At 1:30 p.m., a second request for access to all clinical records for current patients and all discharged patients in the last year were requested. At 3:35 p.m., Staff A stated that clinical records (including eMR) for patient #8 were not available.

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 three (Patients #4, 7 and #8) of eight patients. Findings: Patient #4 A review of the clinical record showed the patient was transferred from the agency on 03/27/23 to inpatient hospital provider services. Documentation showed no transfer summary and no summary of care was provided to the receiving inpatient hospital service provider. Patient #7 Administrative records showed a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date, discharge summary and no summary of care. On 04/12/23 at 10:50 a.m., access to all clinical records for current patients and all discharged patients in the last year were requested. At 11:45 a.m., Staff A stated patient #7 was listed as an active patient on the active patient roster and had been discharged from the agency. At 11:58 a.m., Staff A stated patient #7 was not listed as a discharged patient for the agency on the agency discharge roster for the last year and the date of discharge from the agency was not known. At 3:35 p.m., Staff A stated that clinical records (including eMR) for patient #7 were not accessible to the surveyor for review. Patient #8 Administrative records showed an SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date, discharge summary and no summary of care. At 11:45 a.m., Staff A stated patient #8 was listed as an active patient on the active patient roster; had been referred but was not admitted to the agency; and had been discharged in the eMR system. At 11:58 a.m., Staff A stated patient #8 was not listed as a discharged patient for the agency on the agency discharge roster for the last year and the date of non-admit to the agency was not known. At 1:30 p.m., a second request for access to all clinical records for current patients and all discharged patients in the last year were requested. At 2:20 p.m., limited access to patient clinical records (eMRs) were granted, no clinical record access was granted for patient #8. No documented paper or electronic forms were observed for patient #8 and no paper charts (copies of electronic or paper document originals) were available for review. At 3:35 p.m., Staff A stated that clinical records (including eMR) for patient #8 were not accessible to the surveyor for review.

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 a POC after a comprehensive OASIS assessment for two (Patients #2 and #8) of eight 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: 1. An individualized patient POC included SN interventions and goals for one (Patient #3) of eight patients and; 2. An individualized patient POC included pain and weight reporting parameters 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 and goals to improve their health status. See tag G574. Based on record reviews and interview, the agency failed to ensure an individualized patient POC was reviewed and signed by the physician for one (Patient #6) of eight patients. The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services ordered by their physician for all patients. See tag G588. Based on record review and interview the agency failed to ensure an updated POC was completed after a resumption of care comprehensive assessment for one (Patient #4) of eight patients. The failed practice had the potential to impact the care and services required to meet the continuing health care needs for all patients. See tag G592. Based on record review and interview, the agency failed to ensure patients received the contact information for the agency’s clinical manager at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of the contact information of the agency’s clinical manager related to the provision of care and services by the agency and its personnel. See tag G622. .

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 a POC after a comprehensive OASIS assessment for two (Patients #2 and #8) of eight 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. Patient #2 A review of an administrative record showed a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. On 04/12/23 at 10:50 a.m., access to all clinical records for current patients was requested. At 1:30 p.m., a second request for access to all clinical records for current patients was requested. At 3:35 p.m., Staff A stated that clinical records for patient #2 were unavailable. Patient #8 A review an administrative record showed a SOC date of 10/21/22 and an episode period of 10/21/22 to 12/19/22. Documentation showed no agency discharge date. On 04/12/23 at 10:50 a.m., access to all clinical records for current patients and discharged patients in the last year were requested. At 11:45 a.m., Staff A stated patient #8 was listed as an active patient on the active patient roster; had been referred but was not admitted to the agency; and had been discharged in the eMR system. At 11:58 a.m., Staff A stated patient #8 was not listed as a discharged patient for the agency on the agency discharge roster for the last year and the date of non- At 3:35 p.m., Staff A stated that clinical records for patient #8 were not available.

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: 1. An individualized patient POC included SN interventions and goals for one (Patient #3) of eight patients and; 2. An individualized patient POC included pain and weight reporting parameters 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 and goals to improve their health status. Findings: Patient #3 A review of a POC dated 02/15/23 to 04/15/23 showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed no SN interventions or goals on the POC. Documentation showed SN visits dated 02/23/23, 03/02/23, 03/08/23 and on 04/05/23. Documentation showed no physician notification of no SN interventions or goals on the POC and no change in orders. On 04/12/23 at 3:30 p.m., Staff A stated the POC for patient #3 should have included SN interventions and goals on the POC. Patient #6 A review of the POC dated 03/09/23 to 05/07/23 showed orders for SN to conduct assessment and monitoring of patient pain levels and weight every visit and notify the physician of change. Documentation showed no physician reporting parameters for pain and weight on the POC. Documentation showed SN visits were conducted on 03/23/23 and 04/05/23 and showed no pain assessment and no patient weight monitoring conducted. Documentation showed no patient/caregiver refusal of SN assessment of pain and monitoring of the patient’s weight during the SN visits, no physician notifications and no changes in orders. On 04/12/23 at 3:35 p.m., Staff A stated the POC for patient #6 should have included physician reporting parameters for pain and weight on the POC.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure an individualized patient POC was reviewed and signed by the physician for one (Patient #6) of eight patients. The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services ordered by their physician for all patients. Findings: Patient #6 A review of the clinical record showed no review and signature of physician orders for a POC episode period of 03/09/23 to 05/07/23. Documentation showed SN visits were conducted on 03/23/23 and on 04/05/23 (two SN visits conducted, no visits ordered. Documentation showed no physician notification of the conducted SN visits and no receipt of orders. On 04/12/23 at 3:35 p.m., Staff A stated the POC should have been sent to the physician for review and signature and case communication or physician coordination of care should be documented in the clinical record for patient #6.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure an updated POC was completed after a resumption of care comprehensive assessment for one (Patient #4) of eight patients. Patient #4 A review of the POC for 02/09/23 to 04/09/23 showed a ROC assessment after an inpatient stay on 03/31/23. Documentation showed no updated POC completed after a resumption of care comprehensive assessment. Documentation showed no physician notification after the ROC assessment on 03/31/23 and no physician orders. On 04/12/23 at 3:30 p.m., Staff A stated Patient #4 had a ROC SN visit on 03/31/23 and there was no updated POC after the 03/31/23 ROC assessment for patient #4.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received the contact information for the agency’s clinical manager at the time of admission to the agency for care and services for three (patients #2, 7 and #8) of eight patients. The failed practice denied the patients their right to be informed of the contact information of the agency’s clinical manager related to the provision of care and services by the agency and its personnel. Patient #2 Administrative records show a SOC date of 02/28/20 and a current episode period of 02/12/23 to 04/12/23. No additional clinical or/discharge admission information was provided Patient #7 Administrative records show a SOC date of 09/10/19 and a last episode period of 10/24/22 to 12/22/22, documentation showed no agency discharge date. Patient #8 Administrative records show a SOC date of 10/21/22 and a last episode period of 10/21/22 to 12/19/22, documentation showed no agency discharge date. On 04/12/23 at 10:50 a.m., Clinical records were requested. Neither the clinical record nor patient admission documents provided. At 1:30 p.m., a second request for patient records was requested. No information or copy of the requested forms were provided. At 3:40 p.m., Staff A stated no additional documentation was available.

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 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. See tag G646. Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program which tracked, analyzed and showed implementation of preventative actions of patient events for all patients and employees. The failed practice had the potential to place all patients and employees at risk for adverse patient events. See tag G654. Based on record review and interview, the agency failed to ensure conduction of patient a centered QAPI Program which ensured improvements were measured, tracked and sustained for all patients and employees. The failed practice had the potential to place all patients and employees at risk for ineffective organizational performance improvement activities. See tag G656. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program in calendar years 2021 and 2022 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 a 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 efforts to improve care, services and operations. On 04/12/23 at 10:50 a.m., A request for QAPI records for calendar years 2021 and 2022 yielded no records. At 1:30 p.m., a second request for QAPI records was made made. No QAPI records were provided. At 3:40 p.m., Staff A stated the requested documents were not available.

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. On 04/12/23 at 10:50 a.m., a request for QAPI records for calendar years 2021 and 2022 yielded no records. At 1:30 p.m., a second request for QAPI records was made. No QAPI records were provided. At 3:40 p.m., Staff A stated the requested documents were not 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 all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring. On 04/12/23 at 10:50 a.m., a request for QAPI records yielded no results. At 1:30 p.m., a second request for QAPI records for calendar years 2021 and 2022 were requested. No documentation was provided. At 3:40 p.m., Staff A stated no QAPI records were available.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. 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 which tracked, analyzed and showed implementation of preventative actions of patient events for all patients and employees. The failed practice had the potential to place all patients and employees at risk for adverse patient events. On 04/12/23 at 10:50 a.m., A request for QAPI records for calendar years 2021 and 2022 were requested. No records were provided. At 1:30 p.m., a second request for QAPI records was made. No records were provided At 3:40 p.m., Staff A stated no QAPI records were availalbe.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction 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 ineffective organizational performance improvement activities. On 04/12/23 at 10:50 a.m. a request for QAPI records for calendar years 2021 and 2022 yielded no results. At 1:30 p.m., a second request for QAPI record produced no records. At 3:40 p.m., Staff A stated no QAPI records were not available.

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 in calendar years 2021 and 2022 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. On 04/12/23 at 10:50 a.m. a request for QAPI and PIP records for calendar years 2021 and 2022 yielded no results. At 1:30 p.m., a second request for QAPI/PIP record sproduced no records. At 3:40 p.m., Staff A stated no QAPI or PIP records were available.

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 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. On 04/12/23 at 10:50 a.m., QAPI/PIP and governing body records for calendar years 2021 and 2022 were requested and yielded no results. At 1:30 p.m., a second request for administrative records were requested. No QAPI/PIP or governing body documentation was provided. At 3:40 p.m., Staff A stated QAPI, PIP, governing body and clincal records were unavailable.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure its infection control program included administrative policy and procedures which identified infection control, infection prevention processes and standards for the agency for all patients and staff. The failed practiced placed the agency at risk for potential substandard practices that increased risks for potential patient and staff infections and opportunities for adverse event occurrences throughout the agency for all patients and employees. See tag #G682. 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. The failed practice placed the agency at risk for missed opportunities to identify and reduce the incidence and occurrence of infection throughout the agency and effect the health and well-being of all patients and employees. See tag G684. Based on record review and interview, the agency failed to ensure infection control education was: 1) Included in QAPI activities; 2) Showed interventions to reduce future infections; and 3) Provided and/or maintained for all patients and employees. This failed practiced placed the agency at risk for missed opportunities to identify and correct substandard practices and reduced opportunities to create learning throughout the agency for all patients and employees. See tag G686. .

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure its infection control program included administrative policy and procedures which identified infection control, infection prevention processes and standards for the agency for all patients and staff. The failed practice placed the agency at risk for potential substandard practices that increased risks for potential patient and staff infections and opportunities for adverse event occurrences throughout the agency for all patients and employees. On 04/12/23 at 10:50 a.m., administrative records to include infection control documentation was requested with no success. At 1:30 p.m., a second request for administrative records for the infection control program yielded no records or documenation. At 3:40 p.m., Staff A stated no documentation was available.

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 included in QAPI program activities for all patients and staff. The failed practice placed the agency at risk for missed opportunities to identify and reduce the incidence and occurrence of infection throughout the agency and effect the health and well-being of all patients and employees. On 04/12/23 at 10:50 a.m., administrative records which for the agency’s infection control program, QAPI, PIPs and Governing body was requested with no receipt of documentation. At 1:30 p.m., a second request for the administrative records yielded no requested records. At 3:40 p.m., Staff A stated the requested documentation was unavailable.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure infection control education was: 1) Included in QAPI activities; 2) Showed interventions to reduce future infections; and 3) Provided and/or maintained for all patients and employees. This failed practiced placed the agency at risk for missed opportunities to identify and correct substandard practices and reduced opportunities to create learning throughout the agency for all patients and employees. On 04/12/23 at 10:50 a.m., administrative records for QAPI, PIPs, governing body and the infection control program were requested . No records were provided. At 1:30 p.m., a second request for the administrative records yielded no records provided by the agency. At 3:40 p.m., Staff A stated the requested records were unavailable.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION 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. PT evaluations were conducted for one (Patient #4) of eight patients; 2. OT evaluations were conducted for one (Patient #4) of eight patients; 3. SN to conduct assessment of patient pain every visit and notify the physician of pain level greater than 6 for one (Patients #5) of eight patients; 4. CHHA to conduct visit frequencies as ordered by the physicians for one (Patients #6) of eight and; 5. SN to conduct assessment of patient weight every visit for one (Patients #6) of eight patients. The failed practice had the potential to place patients at risk for poor health outcomes by not receiving care and services as ordered by their physicians. See tag G710. 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. 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 G720. .

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. PT evaluations were conducted for one (Patient #4) of eight patients; 2. OT evaluations were conducted for one (Patient #4) of eight patients; 3. SN to conduct assessment of patient pain every visit and notify the physician of pain level greater than 6 for one (Patients #5) of eight patients; 4. CHHA to conduct visit frequencies as ordered by the physicians for one (Patients #6) of eight and; 5. SN to conduct assessment of patient weight every visit for one (Patients #6) of eight patients. The failed practice had the potential to place patients at risk for poor health outcomes by not receiving care and services as ordered by their physicians. Patient #4 A review of the POC dated 02/09/23 to 04/07/23 showed orders for PT and OT to conduct assessments. A review of clinical documentation showed no PT and OT assessments conducted. Documentation showed no patient/caregiver refusal of PT and OT assessments, no physician notifications and no changes in orders. On 04/12/23 at 3:35 p.m., Staff A stated patient #4 should have had PT and OT assessments. Patient #5 A review of the POC dated 02/27/23 to 04/27/23 showed orders for SN to conduct assessment and monitoring of patient pain levels every visit and notify the physician of pain level greater than 5. A review of clinical documentation showed SN visit conducted on 04/05/23 and showed a pain level of 6. Documentation showed no physician notifications and no changes in orders. On 04/12/23 at 3:35 p.m., Staff A stated the SN should have notified the physician of the patient’s pain level. Patient #6 A review of the POC dated 03/09/23 to 05/07/23 showed orders for SN to conduct assessment and monitoring of patient pain levels and weight every visit and notify the physician of change. Documentation showed no physician reporting parameters for pain and weight on the POC. A review of clinical documentation showed SN visits conducted on 03/23/23 and on 04/05/23 and showed no pain assessment and no patient weight monitoring was conducted. Documentation showed no patient/caregiver refusal of SN assessment of pain and monitoring of the patient’s weight during the SN visits, no physician notifications and no changes in orders. Additional documentation showed a CHHA visit frequency of two times a week for eight weeks. Documentation showed CHHA visits were conducted. Documentation showed no patient/caregiver refusal of CHHA visits, no physician notifications / coordination of care to inform of no CHHA services and no changes in orders. On 04/12/23 at 3:35 p.m., Staff A stated the SN should have been conducted a pain assessment and monitoring of the patient’s weight every visit as ordered by the physician and the physician should have been notified of no CHHA services were in place.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: 716Incomplete clinical notes (SNV, etc.) Based on record review and interview, the agency failed to ensure SN visit notes were completed for four (Patients #3, 4, 5 and #6) of eight patients. Patient #3 A plan of care dated 02/15/23 to 04/15/23 documented a principal diagnosis of arthritis. A review of clinical documentation showed a SN visit frequency of one time a week for nine weeks. Documentation showed SN visits notes on 03/15/23, 03/22/23 and on 03/29/23 were not started, completed and authenticated by the assigned SN. Patient #4 A plan of care dated 02/09/23 to 04/09/23 documented a principal diagnosis of chronic obstructive pulmonary disease. A review of clinical documentation showed a SN visit frequency of one time a week for nine weeks. Documentation showed SN visits notes on 03/15/23 and on 03/22/23 were not started, completed and authenticated by the assigned SN. Patient #5 A plan of care dated 02/27/23 to 04/27/23 documented a principal diagnosis of Diabetes Mellitus Type II. A review of clinical documentation showed a SN visit frequency of one time a week for nine weeks. Documentation showed SN visits notes on 03/21/23, 03/28/23 and on 04/11/23 were not started, completed and authenticated by the assigned SN. Patient #6 A plan of care dated 03/09/23 to 05/07/23 documented a principal diagnosis of urinary incontinence. A review of clinical documentation showed a SN visit frequency of one times a week for eight weeks. Documentation showed SN visits notes on 03/14/23, 03/21/23 and on 03/28/23 were not started, completed and authenticated by the SN. On 04/12/23 at 3:35 p.m., Staff A stated visit notes are to be completed and signed by staff within 24 hour of the visit

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. 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. On 04/12/23 at 10:50 a.m., administrative records for QAPI/PIPs, governing body and infection control for calendar years 2021 and 2022 were requested without results. No requested administrative records were provided. At 1:30 p.m., a second request for the administrative records was made. No administrative records were provided. At 3:40 p.m., Staff A stated the requested documentation and records were not available.

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 a care plan for home health aide services was completed for one (Patient #6) of eight patients. Patient #6 A review of the POC dated 03/09/23 to 05/07/23 showed orders for CHHA visit frequency of two times a week for eight weeks. A review of clinical documentation showed no CHHA care plan (Home Health Aide assignment information) developed and put into place. Documentation showed no patient/caregiver refusal of CHHA visits, no physician notifications / coordination of care to inform of no CHHA services and no changes in orders. On 04/12/23 at 3:35 p.m., Staff A stated the SN who conducted the recertification assessment should have documented a CHHA care plan and the physician should have been notified no CHHA services were in place.

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: 1. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2021 and 2022; and 3. Agency program evaluation for calendar years 2021 and 2022 for all patients and staff. This 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 administrator for the agency for all patients and staff. This failed practice had the potential to effect day to day operational oversite responsibilities of the agency impacting the services its patients received from its staff. See tag G946. Based on record review and interview, the agency failed to ensure a clinical manager was available during all operating hours of the agency for all patients and employees. This failed practice had the potential to effect 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 G950. Based on record review and interview, the agency failed to ensure governing body appointment of an alternate administrator for the agency for all patients and staff. The failed practice had the potential to effect day to day operational oversite responsibilities of the agency impacting the services its patients received from its staff. See tag G954. Based on observation and interview, the agency failed to ensure an administrator or alternate administrator was available during all operating hours for all patients and employees. This failed practice had the potential to place all patients and employees at risk for insufficient administrative oversite of agency services and operations, impact patient outcomes and impact the well-being and safety of all patients and employees. See tag G956. Based on record review and interview, the agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2021 and 2022; and 3. Agency program evaluation for calendar years 2021 and 2022 for all patients and staff. This failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. See tag G942. .

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. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2021 and 2022; and 3. Agency program evaluation for calendar years 2021 and 2022 for all patients and staff. This failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. On 04/12/23 at 10:50 a.m., a request for administrative records for QAPI/PIPs, governing body and infection control documents for calendar year 2021 and 2022 yielded no documents.. At 1:30 p.m., a second request for administrative records yielded no documents. At 3:40 p.m., Staff A stated the requested documents were unavailable.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure a clinical manager was available during all operating hours of the agency for all patients and employees. 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. On 04/11/23 at 9:15 a.m. Observation of the site showed door signage that documented the agency operating hours as Monday through Friday, 9 a.m. to 5 p.m. A sign with the contact number of record for the agency and a secondary contact number (telephone number withheld [originated in Grand Prairie, Texas]). There was no answer to repeated knocks upon the door, no lights were on and shining through the window blinds. Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. At 9:53 a.m., Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes, no personnel were onsite at the agency and requested the agency to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. At 10:00 a.m., 3rd telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left, requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 10:08 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site and no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage. OSDH attempted to contact at the email of record for the designated agency administrator. At 10:20 a.m., 4th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:00 a.m., no personnel for the agency were onsite at the agency and no agency personnel had responded to telephone call or email contact attempts. At 11:06 a.m., 5th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:22 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site, no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage and OSDH attempt to contact at the email of record for the designated agency administrator had no response. At 11:27 a.m., OSDH central office contacted CMS regional office to inform of no agency response to contact attempts by OSDH surveyor. At 11:45 a.m., OSDH surveyor remained onsite outside of the agency from 9:15 a.m. to 11:45 a.m. No agency personnel had arrived at the agency and all contact attempts to the agency had gone unanswered. The survey could not be completed due to the lack of available staff and a closed office. At 9:00 a.m. on 04/12/23, OSDH surveyor arrived at the agency. No answer to multiple knocks on the door and the interior office lights were off. The posted office hours on the sign outside of the door were Monday thru Friday 9 a.m. to 5 p.m. At 9:02 a.m., attempted telephone call to the agency’s telephone number of record (also posted on the outside of the door), telephone was heard ringing inside of the office and then forwarded to a voice mail message identified as the secondary telephone number. Secondary number withheld, location identified as Grand Prairie, Texas was also posted on the outside of the door. A voice mail message was left of attempted survey contact with a request to return the telephone call. At 9:05 a.m., a second telephone call was made to the secondary telephone number (number withheld, [location identified as Grand Prairie, Texas] also posted on the outside of the door); Staff A (identified as the agency administrator) answered the telephone call and confirmed her identity. Staff A was informed OSDH was onsite at the agency for a second attempt to conduct survey. Staff A stated she was not at the office because she was at an appointment; was in Ardmore, Ok. an hour’s drive away from the office location; did not feel well and had tested positive for COVID on a home test last week and was experiencing a cough (denied being officially tested or diagnosed with COVID); had an gas or carbon monoxide leak in the office on Monday and had to leave the office (denied having been evacuated from the office and denied the building had been evacuated for a gas or carbon monoxide leak). Staff A was advised a designated alternate could act as the clinical manager/supervising RN in her absence. Staff A stated she was the administrator, clinical manager and supervising RN for the agency and had no alternate to act on her behalf for the agency and had no office manager/staff to facilitate survey entrance. Staff A stated she would drive to the agency for survey. At 10:18 a.m., Staff A contacted the surveyor by telephone and stated she was still at least a 30 minutes’ drive away from arriving at the agency. At 10:50 a.m., an entrance conference was conducted. Staff A was identified as the contact person for administrative and clinical issues and stated there was no designated alternate clinical manager/supervising RN for the agency and the agency location should have had personnel present on-site during the designated office hours.

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, observation and interview, the agency failed to ensure governing body appointment of an alternate pre-designated person to be available in the absence of the administrator for the agency for all patients and staff. The failed practice had the potential to effect day to day operational oversite responsibilities of the agency impacting the services its patients received from its staff. On 04/11/23 at 9:15 a.m. Observation of the site showed door signage that documented the agency operating hours as Monday through Friday, 9 a.m. to 5 p.m. A sign with the contact number of record for the agency and a secondary contact number (telephone number withheld [originated in Grand Prairie, Texas]). There was no answer to repeated knocks upon the door, no lights were on and shining through the window blinds. Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. At 9:53 a.m., Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes, no personnel were onsite at the agency and requested the agency to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. At 10:00 a.m., 3rd telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left, requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 10:08 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site and no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage. OSDH attempted to contact at the email of record for the designated agency administrator. At 10:20 a.m., 4th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:00 a.m., no personnel for the agency were onsite at the agency and no agency personnel had responded to telephone call or email contact attempts. At 11:06 a.m., 5th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:22 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site, no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage and OSDH attempt to contact at the email of record for the designated agency administrator had no response. At 11:27 a.m., OSDH central office contacted CMS regional office to inform of no agency response to contact attempts by OSDH surveyor. At 11:45 a.m., OSDH surveyor remained onsite outside of the agency from 9:15 a.m. to 11:45 a.m. No agency personnel had arrived at the agency and all contact attempts to the agency had gone unanswered. The survey could not be completed due to the lack of available staff and a closed office. At 9:00 a.m. on 04/12/23, OSDH surveyor arrived at the agency. No answer to multiple knocks on the door and the interior office lights were off. The posted office hours on the sign outside of the door were Monday thru Friday 9 a.m. to 5 p.m. At 9:02 a.m., attempted telephone call to the agency’s telephone number of record (also posted on the outside of the door), telephone was heard ringing inside of the office and then forwarded to a voice mail message identified as the secondary telephone number (number withheld, [location identified as Grand Prairie, Texas] also posted on the outside of the door). A voice mail message was left of attempted survey contact with a request to return the telephone call. At 9:05 a.m., a second telephone call was made to the secondary telephone number (number withheld, [location identified as Grand Prairie, Texas] also posted on the outside of the door); Staff A (identified as the agency administrator) answered the telephone call and confirmed her identity. Staff A was informed OSDH was onsite at the agency for a second attempt to conduct survey. Staff A stated she was not at the office because she was at an appointment; was in Ardmore, Ok. an hour’s drive away from the office location; did not feel well and had tested positive for COVID on a home test last week and was experiencing a cough (denied being officially tested or diagnosed with COVID); had an gas or carbon monoxide leak in the office on Monday and had to leave the office (denied having been evacuated from the office and denied the building had been evacuated for a gas or carbon monoxide leak). Staff A was advised a designated alternate could act as the clinical manager/supervising RN in her absence. Staff A stated she was the administrator, clinical manager and supervising RN for the agency; had no alternate to act on her behalf for the agency; and had no office manager/staff to facilitate survey entrance. Staff A stated she would drive to the agency for survey. At 10:18 a.m., Staff A contacted the surveyor by telephone and stated she was still at least a 30 minutes’ drive away from arriving at the agency. A review of administrative records showed no alternate person appointed by the governing body to be available in the absence of the administrator. At 10:50 a.m., Staff A was identified as the contact person for administrative and clinical issues and stated there was no designated alternate clinical manager/supervising RN for the agency and the agency location should have had personnel present on-site during the designated office hours.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure an administrator or alternate administrator was available during all operating hours for all patients and employees. This failed practice had the potential to place all patients and employees at risk for insufficient administrative oversite of agency services and operations, impact patient outcomes and impact the well-being and safety of all patients and employees. On 04/11/23 at 9:15 a.m. Observation of the site showed door signage that documented the agency operating hours as Monday through Friday, 9 a.m. to 5 p.m. A sign with the contact number of record for the agency and a secondary contact number (telephone number withheld [originated in Grand Prairie, Texas]). There was no answer to repeated knocks upon the door, no lights were on and shining through the window blinds. Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. At 9:53 a.m., Telephone contact was attempted to the telephone number provided to OSDH (contact number of record), the telephone could be heard ringing on the outside of the office door, the answering voice mail message identified the agency and stated the call was diverted to the secondary contact telephone (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes, no personnel were onsite at the agency and requested the agency to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. At 10:00 a.m., 3rd telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call. A voice mail message informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left, requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 10:08 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site and no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage. OSDH attempted to contact at the email of record for the designated agency administrator. At 10:20 a.m., 4th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:00 a.m., no personnel for the agency were onsite at the agency and no agency personnel had responded to telephone call or email contact attempts. At 11:06 a.m., 5th telephone contact was attempted to the secondary telephone number provided on the door signage (telephone number withheld) with no answer to the call and at the telephone number of record for the agency. Voice mail messages informing the agency the OSDH was onsite attempting to enter the agency for survey purposes were left requesting to return the call (telephone number withheld) to the OSDH surveyor as soon as possible. No personnel were onsite at the agency. At 11:22 a.m., Contacted the central office of OSDH to inform the surveyor was unable to contact the agency for survey. No agency personnel had entered the agency site, no personnel had responded to multiple attempts of telephone contact at the telephone numbers posted on the door signage and OSDH attempt to contact at the email of record for the designated agency administrator had no response. At 11:27 a.m., OSDH central office contacted CMS regional office to inform of no agency response to contact attempts by OSDH surveyor. At 11:45 a.m., OSDH surveyor remained onsite outside of the agency from 9:15 a.m. to 11:45 a.m. No agency personnel had arrived at the agency and all contact attempts to the agency had gone unanswered. The survey could not be completed due to the lack of available staff and a closed office. At 9:00 a.m. on 04/12/23, OSDH surveyor arrived at the agency. No answer to multiple knocks on the door and the interior office lights were off. The posted office hours on the sign outside of the door were Monday thru Friday 9 a.m. to 5 p.m. At 9:02 a.m., attempted telephone call to the agency’s telephone number of record (also posted on the outside of the door), telephone was heard ringing inside of the office and then forwarded to a voice mail message identified as the secondary telephone number. Secondary number withheld, location identified as Grand Prairie, Texas was also posted on the outside of the door. A voice mail message was left of attempted survey contact with a request to return the telephone call. At 9:05 a.m., a second telephone call was made to the secondary telephone number (number withheld, [location identified as Grand Prairie, Texas] also posted on the outside of the door); Staff A (identified as the agency administrator) answered the telephone call and confirmed her identity. Staff A was informed OSDH was onsite at the agency for a second attempt to conduct survey. Staff A stated she was not at the office because she was at an appointment; was in Ardmore, Ok. an hour’s drive away from the office location; did not feel well and had tested positive for COVID on a home test last week and was experiencing a cough (denied being officially tested or diagnosed with COVID); had an gas or carbon monoxide leak in the office on Monday and had to leave the office (denied having been evacuated from the office and denied the building had been evacuated for a gas or carbon monoxide leak). Staff A was advised a designated alternate could act as the clinical manager/supervising RN in her absence. Staff A stated she was the administrator, clinical manager and supervising RN for the agency and had no alternate to act on her behalf for the agency and had no office manager/staff to facilitate survey entrance. Staff A stated she would drive to the agency for survey. At 10:18 a.m., Staff A contacted the surveyor by telephone and stated she was still at least a 30 minutes’ drive away from arriving at the agency. At 10:50 a.m., Staff A was identified as the contact person for administrative and clinical issues and stated there was no designated alternate clinical manager/supervising RN for the agency and the agency location should have had personnel present on-site during the designated office hours. A review of administrative records showed no appointment of alternate staff to be available in the absence of the administor (who was also the supervising nurse). Observation during attempted survey on 04/11/23 from 9:0 am until 11:45 am showed no personnel available at the agency. Surveyor time on site on 04/12/23 from 9:00 am until 3:50 pm showed no other staff available.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed transfer summary was provided for one (Patient #4) of eight patients. This failed practice had the potential for improper flow of vital information to receiving facility and/or status of patient at transer. See G1022. Based on record review and interview, the agency failed to ensure accurately documented clinical SN visit notes for two (Patients #3 and #4) of eight patients. This failed practice had the potential for agency-wide poor practices in capturing and documenting accurate patient information assessed at the time of the visit and providing poor history of patient's health status. See G1024 Based on record review, observation and interview, the agency failed to ensure it had administrative and clinical policies and procedures in place related to patient clinical records for all patients and employees. The failed practice placed the agency at risk for potential substandard practices that increased risks for violation of the patients’ right to have an accurate, complete and privacy protected clinical record for all patients. See tag #G1026. Based on observation, record review, and interview, the agency failed to ensure patient paper clinical records were protected from unauthorized access for three (Patients #9, 10 and #11) of 11 patients. The failed practice had the potential to expose patients to unauthorized access to their private personal and health care related information, violating their privacy rights. See tag G1028. .

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 summary was provided for one (Patient #4) of eight patients. This failed practice had the potential for improper flow of vital information to receiving facility and/or status of patient at transer. Patient #4 A review of the clinical record documented transfer from the agency on 03/27/23 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. On 04/12/23 at 3:35 p.m., Staff A stated no transfer summary was sent to the receiving service providers for Patient #4

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure accurately documented clinical SN visit notes for two (Patients #3 and #4) of eight patients. This failed practice had the potential for agency-wide poor practices in capturing and documenting accurate patient information assessed at the time of the visit and providing poor history of patient's health status. Patient #3 A review of the clinical record showed documentation of a SN visit conducted on 03/02/23 was authenticated by the SN on 03/01/23 (one day prior to the SN visit date). Documentation showed no communication, coordination note entries or physician notification of why the SN visit date and the date of the SN visit documentation were on different days. Patient #4 A review of the clinical record showed a SN visits conducted on 03/02/23 was authenticated by the SN on 03/01/23 (one day prior to the SN visit date); and on 03/08/23 was authenticated by the SN on 03/12/23 (four days after the SN visit date). Documentation showed no communication, coordination note entries or physician notification of why the SN visit date and the date of the SN visit documentation were on different days. On 04/12/23 at 3:35 p.m., Staff A stated visit notes should be documented within 24 hours of the visit; and data entry errors should be addressed in communication or coordination note entries for the patients prior to being corrected or backdated.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure it had administrative and clinical policies and procedures in place related to patient clinical records for all patients and employees. The failed practice placed the agency at risk for potential substandard practices that increased risks for violation of the patients’ right to have an accurate, complete and privacy protected clinical record for all patients. On 04/12/23 at 10:50 a.m., OSDH surveyor entered the agency for survey purposes. Three (Patient #1, 9 and #10) patient clinical record binders (paper copies of electronic documents and other paper documents) which identified the patients by name, demographic information, diagnoses, Plan of Care (physician orders) and other privacy protected information were observed visibly lying on an unattended front desk area adjacent to the entrance lobby of the agency. Administrative records which showed administrative policy and procedures related to patient clinical records, including HIPAA compliance standards for the agency were requested during the entrance conference of the survey. No administrative records were provided. At 1:14 p.m., an employment applicant entered the agency, stepped up to the unattended front desk area adjacent to the entrance lobby of the agency (patient clinical record binders for Patients #1, 9 and #10 remained visibly observable), rang the bell for service to inquire about employment positions and requested an employment application. Staff A gave the applicant an employment application and walked away from the front desk area adjacent to the entrance lobby without removing the clinical record binders for Patients #1, 9 and #10. At 1:30 p.m., a second request for administrative records which showed administrative policy and procedures related to patient clinical records, including HIPAA compliance standards for the agency were requested. No administrative records were provided. At 3:40 p.m., Staff A stated the patient clinical record binders for patients #1, 9 and #10 should have not been on the unattended front desk area adjacent to the entrance lobby of the agency.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patient paper clinical records were protected from unauthorized access for three (Patients #1, 9 and #10) of 10 patients. The failed practice had the potential to expose patients to unauthorized access to their private personal and health care related information, violating their privacy rights. On 04/12/23 at 10:50 a.m., OSDH surveyor entered the agency for survey purposes. Three (Patient #1, 9 and #10) patient clinical record binders (paper copies of electronic documents and other paper documents) which identified the patients by name, demographic information, diagnoses, Plan of Care (physician orders) and other privacy protected information were observed visibly lying on an unattended front desk area adjacent to the entrance lobby of the agency. At 1:14 p.m., an employment applicant entered the agency, stepped up to the unattended front desk area adjacent to the entrance lobby of the agency (patient clinical record binders for Patients #1, 9 and #10 remained visibly observable), rang the bell for service to inquire about employment positions and requested an employment application. Staff A gave the applicant an employment application and walked away from the front desk area adjacent to the entrance lobby without removing the clinical record binders for Patients #1, 9 and #10. At 3:40 p.m., Staff A stated the patient clinical record binders for patients #1, 9 and #10 should have not been on the unattended front desk area adjacent to the entrance lobby of the agency.