Every finding on record at Eton Home Healthcare, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness survey at the agency on 03/03/22 and 03/04/22. No deficiencies were cited as a result of the survey. The agency was found to be in compliance with the Emergency Preparedness Conditions for Participation.

The Oklahoma State Department of Health conducted an unannounced Medicare recertification at the agency on 03/03/22 and 03/04/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Findings were discussed during an informal pre-exit conference with Staff A on 03/03/22 and by phone with Staff B on 03/04/22. Standard level deficiencies were cited as a result of the Medicare re-certification survey. OKSCREEN An Oklahoma based national background check program with fingerprinting

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure complaint documentation showed a complete complaint investigation and resolution for five (Complaints #2, 3, 4, 5 and 6) of seven complaints reviewed. Complaints #2, 3, 4, 5 and 6 A review of the agency's complaint logs showed a brief summary and date of the complaints. Documentation failed to show a complete investigation, resolution or that the client/patient was or was not satisfied with the outcome. On 03/03/22 at 12:28 pm, Staff A stated she didn't realize a full investigation and resolution was required but did not answer the question as asked.

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's governing body failed to ensure it defined and approved the QAPI program for all agency staff and patients. A review of administrative and QAPI records showed no governing body approval of a QAPI program and QAPI activities or what constituted or defined the QAPI program. On 03/03/22 at 12:41 pm, Staff A showed non-verbal confirmation that there was no documented governing body approval or definition or required activities, but did not verbally answer.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review an interview, the agency failed to ensure all staff were were either fully vaccinated or exempted from vaccination for two (Staff 1 and Staff 5) of five staff. A review of staff COVID-19 vaccination records showed no vaccine status for Staff #1 and no pending or approved exemption. Documentation showed no vaccine status for previously unidentified Staff 5 and no pending or approved exemption. On 03/05/22 at 1:50 pm, Staff A stated: 1) the vaccine status for Staff 1 was not shown 2) Staff #5 was an employee and 3) There was no vaccine status shown for Staff #5.

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's governing body failed to ensure: 1) documented review of budget and operations plan and 2) a review of the QAPI Program for all agency patients and staff. A review of the agency's governing body and administrative records showed no review of the agency's budget, operations or the QAPI Program. On 03/03/22 at 12:41 pm, Staff A showed non-verbal confirmation that there was no documented governing body review or approval of the QAPI program and no review of the budget or operations plan, but did not verbally answer the question.