Every finding on record at Good Health Care Professionals, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/13/21 through 04/14/21. Standard level deficiencies were cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 26 patients and all employees. Findings: A review of administrative records showed no dated emergency preparedness community-based risk assessment which identified the agency, its patient population, or its employees. On 04/14/21 at 12:30 p.m., Staff A stated the agency had no dated emergency preparedness community-based risk assessment which identified the agency, its patient population, or its employees.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan which included required information related to staff members, resources of the agency and community contacts. Findings: A review of administrative records showed no Emergency Preparedness Communication Plan which included required information related staff members, resources of the agency and community contacts. On 04/14/21 at 12:30 p.m., Staff A stated the agency did not have an Emergency Preparedness Communication Plan which included required information related staff members, resources of the agency and community contacts.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an emergency preparedness disaster table top exercises and drills were conducted for fiscal year's 2019 and 2020 for 26 patients and all staff members. Findings: A review of administrative records related to emergency preparedness showed no agency disaster table top exercises, drills or participation in community based drills for calendar year's 2019 and 2020. On 04/14/21 at 12:30 p.m., Staff A stated the agency had no documentation of emergency preparedness disaster table top exercises, drills or participation in community based drills for calendar year's 2019 and 2020.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/13/21 through 04/14/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative issues and Staff C and D were identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff A and D. The following Condition level deficiency was cited as a result of the Medicare re-certification survey: 484.65 Quality Assessment and Performance Improvement. Glossary: BP Blood pressure Pts Patients PIP Performance Improvement Project QAPI Quality Assurance Performance Improvement SN Skilled Nurse

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of BP levels greater than the ordered reporting parameter for two (Pt's #1 and #4) of seven patients. Findings: Patient #1 A review of the POC dated 02/24/21 to 04/24/21 documented SN to report BP greater than systolic pressure of 170 and a diastolic pressure of 100. A review of clinical notes showed on 03/08/21 BP of 182/86, 03/25/21 BP of 182/86 and on 04/05/21 BP of 212/187. Documentation showed no physician notification of the BP levels. Patient #4 A review of the POC dated 03/09/21 to 05/07/21 documented SN to report BP greater than systolic pressure of 170 and a diastolic pressure of 100. A review of clinical notes showed on 03/22/21 a BP of 173/68. Documentation showed no physician notification of the BP level. On 04/14/21 at 1:00 p.m., Staff C stated the physician should have been notified of BP levels greater than the reporting parameters for Pt's #1 and #4 at the time of the skilled visits.

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 26 patients and employees. This failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G642. Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 26 patients and all employees. This failed practice had the potential to place all patients and employees 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 26 patients and all employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G646. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 26 patients and all employees. This failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See tag G658. Based on record review and interview the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for 26 patients and all employees. This 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 26 patients and employees. This failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency for calendar year's 2019 or 2020. On 04/14/21 at 9:30 a.m., Staff C stated there was no documentation which showed a QAPI program for calendar year's 2019 or 2020.

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 26 patients and all employees. This failed practice had the potential to place all patients and employees at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: A review of administrative records showed no data collection activities utilized in an agency QAPI Program for calendar year's 2019 and 2020. On 04/14/21 at 9:30 a.m., Staff A stated: 1. They had no analysis of data collected available that showed improved quality of patient care; and 2. Program improvement data was 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 26 patients and all employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar year's 2019 and 2020. On 04/14/21 at 9:30 a.m., Staff A stated they had no agency QAPI documentation which showed QAPI program activities.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 26 patients and all employees. This failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs in calendar year's 2019 and 2020. On 04/14/21 at 9:30 a.m., Staff A stated the agency had no documentation which showed PIP activities for calendar year's 2019 and 2020.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for 26 patients and all employees. This failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities and no quarterly QAPI meetings to improve the care, services, and operations of the agency for calendar year's 2019 and 2020. On 04/14/21 at 9:30 a.m., Staff A stated they had no documentation which showed governing body oversite of QAPI program activities for calendar year's 2019 and 2020.

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: 1. The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency; and 2. The Infection Control Program was included in QAPI activities. Findings: A review of administrative records showed no ongoing infection control program for the agency or infection control surveillance data for calendar year's 2019 and 2020. On 04/14/21 at 12:30 p.m., Staff C stated: 1) The agency had no documented infection control program or infection control program surveillance activities for calendar year's 2019 and 2020; and 2) The agency should have infection control data as part of their comprehensive infection control program.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. patient centered QAPI Program; 2. infection control program activities and; 3. operating budget and allocation of resources for calendar year's 2019 and 2020 for 26 patients and all staff. Findings: A review of administrative records showed no: 1) governing body oversite of an ongoing patient centered QAPI program; 2) governing body oversite infection control program activities and; 3) governing body oversite of the operating budget, capital expenditure plan, or allocation of resources for the agency in calendar year's 2019 and 2020. On 04/14/21 at 10:00a.m., Staff A stated there was no documentation which showed evidence of: 1. governing body oversite of the agency's QAPI program and QAPI program activities; 2. governing body oversite infection control program activities and; 3. governing body discussion of the operating budget, capital expenditure plan, or resource allocation needs for the agency for calendar year's 2019 and 2020.

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 a record review and interview, the agency failed to ensure an RN Clinical Manager was available during operating hours to oversee the provision of care and professional services for 26 patients. Findings: A review of administrative records showed no alternate supervising nurse appointed by the governing body for the agency. On 04/13/21 at 11:00 a.m., Staff B stated the RN Clinical Manager (Staff D) had not responded to contact by telephone call. Staff D was not available for the duration of the survey. On 04/14/21 at 9:00 a.m., Staff A stated the RN Clinical Manager (Staff D) was not available for survey and Staff C would answer survey questions related to clinical issues. At 10:50 a.m., Telephone call contact attempts to Staff D were unanswered. At 12:00 p.m., Staff A stated: 1. Staff D was the RN Clinical Manager for the agency; 2. Staff D was not available during the survey and; 3. there was no alternate supervising nurse for the agency.