Every finding on record at Faith Home Care Services, L.L.C.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 11/05/24 to 11/06/24. No deficiencies were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 11/05/24 to 11/06/24. An entrance conference was conducted with Staff A. The survey process was explained, and questions were answered. Staff B was identified as the contact persons for administrative issues and Staff C was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: CHHA Certified Home Health Aide Pt Patient SN Skilled Nurse

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1) SN frequencies were followed as ordered for one (Pt #5) of seven patients; and 2) CHHA frequencies were followed as ordered for one (Pt #6) of seven patients. Findings: Pt #5 A review of a POC dated 07/05/24 - 09/02/24 showed orders for a SN frequency of once a day for 60 days. Documentation showed no SN visits 07/11/24, 07/13/24, 07/14/24, 07/16/24, 07/16/24, 07/17/24, 07/20/24, 07/21/24,07/22/24, 07/24/24, 07/26/24, 07/27/24, 07/28/24, 07/30/24, and 7/31/24. Documentation showed no orders for SN frequency changes, no patient/caregiver refusal and no missed visit notes for these dates. Pt #6 A review of the POC dated 08/08/24 to 10/06/24 showed CHHA visits ordered twice a week for one week, five times a week for one week, four times a week for one week, three times a week for two weeks, twice a week for two weeks, and once a week once a week for two weeks. A review of the clinical record showed for the week of 09/01/24 - 09/07/24 one missed visit completed; one visit completed (one visit missing). Documentation showed no orders for CHHA frequency changes, no patient/caregiver refusal of visits and no other missed visit notes. On 11/06/24 at 1255 Staff C stated the CHHA visit frequency was not followed for the week of 09/01/24 - 09/07/24.

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 oversight of the agency's budget and policies and procedures for all agency patients and staff employed by the agency for 2023 and 2024. A review of administrative records from November 5, 2022 - November 6,2024 showed no approval of the budget and no approval of policy and procedure. Findings: On 11/06/24 governing board meeting minutes were reviewed from November 5, 2022 - November 6,2024. The governing body did not approve the budget or policy and Policy and Procedure Manual. On 11/06/24 at 12:34 pm, Staff B reported she was unaware the governing body should be approving the budget and Policy and Procedure Manual annually.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a referral was provided by a physician for one (Patient #2) of seven patients. Findings: Patient #2 A review of the clinical record showed no referral for admission date of 04/19/24. On 11/06/20 at 11:50 am, Staff C stated there was no referral in the clinical record for Pt #2.

A Medicare Emergency Preparedness follow-up survey was completed on 02/10/22. All deficiencies were removed as a result of the survey.

The Oklahoma State Department of Health completed an unannounced Medicare re-certification follow-up survey at the agency on 02/10/22. All conditions were removed as a result of the survey. The agency was found to be in compliance with the conditions of participation for home health agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by:

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by:

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:

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:

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: