Every finding on record at Good Journey Home Health, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/05/24 to 03/07/24.Deficiencies were cited as a result of the Emergency Preparedness Program survey.

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 an emergency preparedness disaster tabletop exercises or disaster drill were conducted for calendar years 2022 and 2023 for all patients and current staff members. A review of the agency's disaster/emergency preparedness records showed no tabletop exercise or disaster drill for the surveyed agency within the past two years. On 03/07/24 at 11:05 a.m., Staff A stated there was no documentation of an emergency preparedness disaster table-top exercises or drills for 2022 and 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/05/24 to 03/07/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B was identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff B and C. The following condition level deficiency was cited: 484.65 Quality Assessment and Performance Improvement Glossary: POC Plan of Care SN Skilled Nurse/Nursing HHA Home Health Aide QAPI Quality Assurance and Performance Improvement PIP Performance Improvement Project

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an individualized patient POC included the frequency and duration of visits to be made for seven (Patients #2, 3, 5, 8, 9, 11, and 12) of thirteen patients. Patient #2 A review of a POC dated 02/17/23 to 04/17/23 showed a SN frequency of one visit per week and no duration of visits. Patient #3 A review of a POC dated 04/07/23 to 06/05/23 showed a SN frequency of one visit per week and no duration of visits, and a HHA frequency of two visits per week and no duration of visits. Patient #5 A review of a POC dated 03/23/23 to 05/21/23 showed a SN frequency of one visit per week and no duration of visits, and a HHA frequency of one visit per week and no duration of visits. Patient #8 A review of a POC dated 04/12/23 to 06/10/23 showed no SN frequency and no duration of visits. Patient #9 A review of a POC dated 05/18/23 to 07/16/23 showed a SN frequency of one visit per week and no duration of visits. Patient #11 A review of a POC dated 03/25/23 to 05/23/23 showed a SN frequency of one visit per week and no duration of visits, and a HHA frequency of two visits per week and no duration of visits. Patient #12 A review of a POC dated 04/04/23 to 06/02/23 showed a SN frequency of one visit per week and no duration of visits, and a HHA frequency of five visits per week and no duration of visits. On 3/7/24 at 10:35 a.m., Staff B stated the POC did not contain the duration of visits to be made for Patients #2, 3, 5, 8, 9, 11, and 12.

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: Based on record review and interview, the agency failed to ensure SN frequencies were followed as ordered for two (Patients #2 and 4) of thirteen patients. Patient #2 A review of a POC dated 02/17/23 to 04/17/23 showed a SN frequency of one visit per week and no duration of visits. A review of the medical records showed: No SN visits were made for the week of 03/05/23 to 03/11/23. No SN visits were made for the week of 03/19/23 to 03/25/23. No SN visits were made for the week of 04/02/23 to 04/08/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #4 A review of a POC dated 02/25/23 to 04/25/23 showed a SN frequency of zero visit per week for one week, one visit per week for seven weeks, two visits per week for one week, and zero visit per week for one week. A review of the medical records showed a SN visit dated 04/20/23, and no other visits made for the week of 04/16/23 to 04/22/23 (one of two ordered visits completed). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. On 3/7/24 at 10:45 a.m., Staff B stated the SN frequencies for Patient #2 and Patient #4 were not met as ordered.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN obtained an order for oxygen administration for one (Patient #6) of thirteen patients. Patient #6 A review of the POC dated 03/30/23 to 05/28/23 showed no order for oxygen to be administered to the patient. A review of the medical records showed the following: A SN visit note dated 04/26/23 documented the patient intermittently received 2 liters of oxygen per minute via nasal cannula. Documents showed no oxygen administration was ordered by the physician. A SN visit note dated 05/10/23 documented the patient intermittently received 2 liters of oxygen per minute via nasal cannula. Documents showed no oxygen administration was ordered by the physician. On 3/7/24 at 10:45 a.m., Staff B stated the plan of care did not show an order for oxygen use and there were no orders by the physician to administer oxygen for Patient #6.

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 a patient centered QAPI Program for all 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 G642. Based on record review and interview the agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees. This failed practice had the potential to place all patients and employees at risk for poor quality of care due to missed opportunities by the agency to detect and correct problem areas. See G646. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for all patients and employees. This failed practice had the potential to place the agency and 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 G658. .

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 a patient centered QAPI Program for all 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. A review of administrative records showed no documentation of a QAPI program developed, implemented, or sustained for calendar years 2022 and 2023. On 03/07/24 at 9:35 a.m., Staff B stated there was no QAPI program for 2022 and 2023.

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. This failed practice had the potential to place all patients and employees at risk for poor quality of care due to missed opportunities by the agency to detect and correct problem areas. A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar years 2022 and 2023. On 03/07/24 at 9:35 a.m., Staff B stated there was no QAPI program activities developed for 2022 and 2023.

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 all patients and employees. This failed practice had the potential to place the agency and all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. A review of the agency’s PIP project showed no initiation, review, data analysis, or status of PIPs for calendar years 2022 and 2023. On 03/07/24 at 9:35 a.m., Staff B stated there was no PIP project developed for 2022 and 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/20/21 - 04/21/21. A deficiency was cited as a result of the Medicare 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 hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 80 patients and all employees. Findings: A review of administrative records showed no community-based risk assessment which addressed the agency, its patient population, or its employees for the calendar years of 2019 and 2020. On 04/21/21 at 12:50 pm, Staff A stated he didn't have a dated risk assessment for 2019 or 2020.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/20/21 - 04/21/21. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person 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. Deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: OT Occupational Therapist PIP Performance Improvement Plan PIPS Performance Improvement POC Plan of Care Pt Patient PT Physical Therapy QAPI Quality Assessment and Performance Improvement SN Skilled Nurse SOC Start of Care

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was performed within 48 hours of the referral for one (Pt #2) of seven patients. Findings: Pt #2 A review of the clinical record showed a patient referral dated 07/31/20. Documentation showed an initial patient assessment and SOC dated 08/03/20 (three days later). Documentation showed no physician request to delay the initial assessment. On 04/21/21 at 11:42 am, Staff C stated the initial assessment for Pt #2 was not within 48 hours of the referral and there was no documentation as to why the admission was not done within 48 hours of the referral.

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: Based on record review and interview, the agency failed to ensure SN frequencies were followed as ordered for one (Pt #4) of seven patients. Findings: Pt #1 A review of a POC dated 03/01/21 - 04/29/21 showed orders for a SN frequency of once a week for nine weeks. Documentation showed no SN visit the week of 04/11/21 - 04/17/21 (there was a blank note for 04/12/21). Documentation showed no orders for SN frequency changes, no patient/caregiver refusal and no missed visit note. Pt #4 A review of the POC dated 02/13/21 to 04/13/21 showed SN visits ordered starting 02/14/21 for twice a week for three weeks, once a week for four weeks, twice a week for one week and then once a week for one week. A review of the clinical record showed one visit completed the week of 02/14/21 - 02/20/21 (one visit missing), one visit completed the week of 02/21/21 - 02/27/21 (one visit missing) and one visit completed the week of 02/28/21 - 03/06/21 (one visit missing). Documentation showed no orders for SN frequency changes, no patient/caregiver refusal of visits and no missed visit notes. On 04/21/21 at 12:00 pm, Staff C stated the ordered SN frequency was not followed for Pt #1 and 4.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. wound care was ordered for one (Pt #3) of seven patients; 2. an OT evaluation was ordered for one (Pt #6) of seven patients; 3. a PT evaluation was ordered for one (Pt #6) of seven patients. Findings: Pt #3 A review of a POC dated 03/12/21 - 05/10/21 showed a primary diagnosis of chronic venous hypertension with ulcer and inflammation. POC documentation showed no specific ordered wound care and no orders later written for wound care. A SN note dated 03/15/21 documented "cleansed wound with normal saline and patted dry, mupirocin applied to wound bed, covered with clean 4x4 gauze and secured with medipore tape". A SN note dated 04/06/21 documented "wound care performed as ordered." Pt #6 A review of a POC dated 01/11/21 to 03/11/21 showed no orders for OT and PT to evaluate. A review of the electronic medical record showed no orders for OT or PT to complete and evaluation. A review of clinical documentation showed an OT evaluation completed 02/01/21 and a PT evaluation completed 02/03/21. On 04/21/21 at 12:00 p.m., Staff C stated: 1. There was no wound care ordered for Pt #3; 2. There was no order for an OT evaluation for Pt # 6; 3. There was no order for a PT evaluation for Pt #6.

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 quality indicators were analyzed for 80 current patients, patients on services during calendar years 2019 and 2020, and all employees. Findings: A review of administrative records showed no analysis of quality indicators for 2019 and 2020. On 04/21/21 at 12:55 pm, Staff A stated there he was unable to provide analysis of quality indicators for 2019 and 2020.

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 a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements was sustained for all patients and employees. Findings: A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency for calendar years of 2019 and 2020. On 04/10/21 at 12:55 p.m., Staff A stated he was unable to provide documentation to show a patient centered QAPI program.

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 80 patients and all employees. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs for 2019 or 2020 for the surveyed agency. On 04/21/21 at 12:55 pm, Staff A stated they were unable to provide documented PIP activities for 2019 and 2020.

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, QAPI Program and policies and procedures for all agency patients and staff employed by the agency during 2020. A review of administrative records for calendar year of 2020 showed no review and approval of: 1) annual budget; 2) comprehensive QAPI program and PIP/PIPS; 3) policy and procedures. Findings: On 04/20/21 at 9:22 am the Surveyor requested the last two years of governing body minutes. The surveyor requested the governing body minutes for the calendar year 2020. The request yielded no governing body documentation for 2020. On 04/21/21 at 12:55 pm, Staff A reported he was unable to provide the requested governing body minutes for 2020.