Every finding on record at Grayson Home Health, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/22/25. 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 01/22/25. An entrance conference was conducted with Staff A. The survey was explained. Questions were answered. Staff A was identified as the contact person for clinical issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the re-certification survey. Glossary: HHA Home Health Aide POC Plan of Care Pt Patient QAPI Quality Assessment and Performance Improvement

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 POC was developed for two (Pt #4 and 5) of seven patients. Findings: Pt #4 A POC dated 12/31/24 to 02/28/25 showed orders for the staff to notify the physician if the heart rate was less than 90. No other documentation was shown for the heart rate. Pt #5 A POC dated 12/25/24 to 02/22/25 showed a HHA frequency of once a week for one week and then twice a week for eight weeks effective 11/11/24. Continued review of the clinical record showed the HHA frequency was for the former certification period. On 01/22/25 at 3:50 pm Staff A stated: 1) The POC for Pt #4 with orders for physician notification of a heart rate of less than 90 was an error; 2) The POC for Pt #5 the staff who did the recertification must not have changed the effective date of the HHA frequency.

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 document PIPs conducted through their QAPI Program for all employees and 53 current patients for 2024. Findings: A review of QAPI records showed no PIPs initiated or documented for 2024. On 01/22/25 at 2:00 pm, Staff B stated she had not created a PIP for 2024.

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 the governing body provided oversight of agency operations and programs for 53 current patients and all employees. Findings: A review of Governing Body Minutes showed no governing body review or approval of the annual budget in the 03/20/2024 minutes. On 01/22/25 at 1:13 pm Staff B stated the governing body minutes for 2024 did not show review or approval of the annual budget for the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/29/22 and 03/30/22. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/29/22 and 03/30/22.An entrance conference was conducted with Staff 1. The survey process was explained. Questions were answered.Staff1 was identified as the contact person for administrative and clinical issues.Findings were discussed during an informal exit conference with Staff1.A deficiency was cited as a result of the re-certification survey.GLOSSARY:HHA Home Health AideSAV Supervisory Aide Visit RN Registered Nurse

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the RN failed to conduct onsite Supervisory Aide Visits at least every 14 days for 2 (#3 and #5) of 3 (#1, #3 and#5) patients records reviewed with orders for HHA services. Pt#3A review of the electronic medical record showed SAVs were conducted by the RN on 2/21/22, 3/8/22 (1 day late), 3/14/22 and 3/29/22 (1 day late). Pt#5A review of the electronic medical record showed SAVs were conducted by the RN on 3/14/22 and 3/29/22 (1 day late). On 03/30/22 at 1:45 PM, Staff 1 stated the Supervisory Aide Visits for Pt#3 and Pt#5 had not been conducted at least every 14 days by the RN as required.