Every finding on record at Guarding Angels Home Health LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/11/26 to 03/13/26. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the Emergency Preparedness Plan had policies and procedures related to patient data management and information sharing for all patients and employees. Findings: A review of emergency preparedness records showed no Emergency Preparedness Plan policies and procedures related to patient data management and information sharing. On 03/13/26 at 8:52 a.m., Staff A stated the agency had no policies and procedures for patient information sharing.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Emergency Preparedness communication plan included current employee contact information for all patients and employees. Findings: A review of emergency preparedness records showed no communication plan which included current employee contact information for the agency. On 03/13/26 at 8:52 a.m., Staff A stated its emergency preparedness communication plan did not include contact information for current employees.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation, and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of emergency preparedness records showed no administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials. On 03/13/26 at 8:52 a.m., Staff A stated its emergency preparedness plan did not include processes and resource contact information for an integrated response.

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 emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2024 for all patients and employees. Findings: A review of emergency preparedness records showed no disaster table-top exercises, drills, community drills or plan activation events for calendar year 2024. On 03/13/26 at 8:52 a.m., Staff A stated the agency had no exercises, drills, or events in 2024.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/11/26 to 03/13/26. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff A. Standard level deficiencies were cited as a result of the survey. Glossary: OT occupational therapy PT physical therapy PIP performance improvement project POC Plan of Care QAPI quality assessment performance improvement SN skilled nurse

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 reviews and interviews, the agency failed to ensure individualized POCs included: 1.Pain management reporting parameters for eight (Patients #1, 2, 3, 4, 5, 6, 7 and #8) of nine patients. 2.Vital sign assessment reporting parameters for blood pressure, pulse, temperature and respiratory rate for eight (Patients #1, 2, 3, 4, 5, 6, 7 and #8) of nine patients. 3.Identification of wound care sites for five (Patients #1, 2, 5, 7 and #9) of nine patients. 4.Pulse Oximeter oxygen saturation reporting parameter for one (Patient #3) of nine patients. 5.Wound care intervention for two (Patients #4 and #6) of nine patients. 6.Physical therapy to evaluate and treat for one (Patient #4) of nine patients. Findings: Patient #1 A review of a POC dated 02/12/26 to 04/12/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 02/10/26 showed a pain level of 3 of 10 and documented no wound site location. 02/17/26 showed a pain level of 4 of 10 and documented no wound site location. 02/24/26 showed a pain level of 5 of 10 and documented no wound site location. 03/03/26 showed a pain level of 3 of 10 and documented no wound site location. On 03/13/26 at 9:12 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment from the prior POC because the wound site had healed. Patient #2 A review of a POC dated 01/13/26 to 03/13/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 01/14/26 showed a pain level of 4 of 10 and documented no wound site location. 01/21/26 showed a pain level of 4 of 10 and documented no wound site location. 01/28/26 showed a pain level of 4 of 10 and documented no wound site location. 02/04/26 showed a pain level of 4 of 10 and documented no wound site location. 02/11/26 showed a pain level of 6 of 10 and documented no wound site location. 02/18/26 showed a pain level of 4 of 10 and documented no wound site location. 02/25/26 showed a pain level of 4 of 10 and documented no wound site location. 03/02/26 showed a pain level of 4 of 10 and documented no wound site location. On 03/13/26 at 9:32 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment from the prior POC because the wound site had healed. Patient #3 A review of a POC dated 02/06/26 to 04/06/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess oximeter oxygen saturation level every visit. The POC showed no reporting parameters for pain management, vital sign readings and showed no oxygen saturation reporting parameters. SN visits dated: 02/09/26 showed a pain level of no pain and showed an oxygen saturation of 96 percent on 2 liters of oxygen. 02/11/26 showed a blood pressure of 98/70 with a pulse rate of 111 beats per minute. 02/16/26 showed a pain level of no pain and showed an oxygen saturation of 95 percent on 4 liters of oxygen. 02/23/26 showed a pain level of no pain and showed an oxygen saturation of 96 percent on 2 liters of oxygen. 03/02/26 showed a pain level of no pain and showed an oxygen saturation of 96 percent on 2 liters of oxygen. On 03/13/26 at 9:32 a.m., Staff A stated the POC did not include pain, vital sign or oxygen saturation reporting parameters. Patient #4 A review of a POC dated 01/31/26 to 03/31/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and perform wound care interventions to the Sacrum of cleanse with normal saline, apply calcium alginate and Medi-honey and cover with bordered foam dressing two times a week and physical therapy to evaluate and establish treatment plan. The POC showed no reporting parameters for pain management or vital sign readings and showed no PT referral or evaluation. SN visits dated: 02/04/26 showed a pain level of no pain and documented no wound site interventions. 02/11/26 showed a pain level of no pain and documented no wound site interventions. 02/18/26 showed a pain level of 2 of 10 and documented no wound site interventions. 02/25/26 showed a pain level of 2 of 10 and documented no wound site interventions. 03/02/26 showed a pain level of 4 of 10 and documented no wound site interventions. On 03/13/26 at 9:32 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site interventions from the prior POC because the wound interventions and SN visit frequency had changed. 3.The POC should not have included PT evaluation that was conducted in the prior certification period. Patient #5 A review of a POC dated 01/06/26 to 03/06/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess and measure the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 01/12/26 showed a pain level of 3 of 10 and documented no wound site location or measurements. 01/19/26 showed a pain level of 6 of 10 and documented no wound site location or measurements. 01/26/26 showed a pain level of 5 of 10 and documented no wound site location or measurements. 02/02/26 showed a pain level of 6 of 10 and documented no wound site location or measurements. 02/09/26 showed a pain level of 6 of 10 and documented no wound site location or measurements. 02/16/26 showed a pain level of 5 of 10 and documented no wound site location or measurements. 02/23/26 showed a pain level of 7 of 10 and documented no wound site location or measurements. 03/02/26 showed a pain level of 7 of 10 and documented no wound site location or measurements. On 03/13/26 at 10:15 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment and measurement interventions from the prior POC because the wound site had healed. Patient #6 A review of a POC dated 02/21/26 to 04/21/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and perform wound care interventions to the left posterior leg of cleanse with normal saline, apply lactic acid 15%, Gentamycin and Acticoat cover with absorbent pad dressing two times a week. The POC showed no reporting parameters for pain management or vital sign readings. SN visits dated: 02/25/26 showed a pain level of 4 of 10 and documented wound site interventions at a one time a week frequency. 03/02/26 showed a pain level of 3 of 10 and documented wound site interventions at a one time a week frequency. On 03/13/26 at 10:25 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site interventions from the prior POC at frequency two times a week after they were changed to one time a week. Patient #7 A review of a POC dated 02/08/26 to 04/08/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 02/12/26 showed a pain level of no pain and documented no wound site location. 02/19/26 showed a pain level of 3 of 10 and documented no wound site location. 02/26/26 showed a pain level of 3 of 10 and documented no wound site location. 03/05/26 showed a pain level of 3 of 10 and documented no wound site location. On 03/13/26 at 10:50 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment from the prior POC because the wound site had healed. Patient #8 A review of a POC dated 02/02/26 to 04/02/26 showed orders for SN to observe, assess and teach pain management and perform assessment of vital signs every visit. The POC showed no reporting parameters for pain management or vital sign readings. SN visits dated: 02/06/26 showed a pain level of 4 of 10. 02/09/26 showed a pain level of 3 of 10. On 03/13/26 at 11:00 a.m., Staff A stated the POC did not include pain or vital sign reporting parameters. Patient #9 A review of a POC dated 01/01/26 to 03/01/26 showed orders for SN to assess and measure the wound site every visit. The POC did not identify a wound site location. SN visits dated: 01/06/26 showed no wound site location or measurements. 01/13/26 showed no wound site location or measurements. 01/21/26 showed no wound site location or measurements. On 03/13/26 at 11:10 a.m., Staff A stated the POC should not have included wound site assessment and measurement from the prior POC because the wound site had healed.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded 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 orders were documented for wound care interventions for one (Patient #4) of nine patients. Findings: Patient #4 A review of the clinical record showed agency receipt of a faxed order dated 01/28/26 for a SN visit frequency of one-time a week to perform wound site treatment interventions to the Sacrum of wound cleanser, apply skin prep and collagen and cover with gauze dressing. The clinical record showed no entry of the order. On 03/13/26 at 10:00 a.m., Staff A stated the order dated 01/28/26 was not entered into the patient’s record.

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 utilization and analysis of patient outcome data in its QAPI Program for all patients and employees. Findings: A review of QAPI records showed no patient outcome data was utilized for analysis and decision making in its QAPI program in calendar years 2024 and 2025. On 03/13/26 at 11:20 a.m., Staff A stated patient outcome data was not included in the 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 baseline and goal measurements of the PIP through their QAPI Program for all patients and employees. Findings: A review of QAPI records showed no PIP baseline and goal measurements in calendar years 2024 and 2025. On 03/13/26 at 11:20 a.m., Staff A stated the PIP showed no measurable goals for 2024 and 2025.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure: 1.SN visit frequency was conducted as ordered for two (Patients #4 and #6) of nine patients. 2.Aide visit frequency was conducted as ordered for one (Patient #8) of nine patients. Findings: Patient #4 A review of a POC dated 01/31/26 to 03/31/26 showed orders for SN visit frequency of two times a week for nine weeks. The clinical record showed SN visit during the weeks of: 02/01/26 to 02/07/26 SN visit was conducted on 02/04/26 (two visits ordered, one visit conducted). 02/08/26 to 02/14/26 SN visit was conducted on 02/11/26 (two visits ordered, one visit conducted). 02/15/26 to 02/21/26 SN visit was conducted on 02/18/26 (two visits ordered, one visit conducted). 02/22/26 to 02/28/26 SN visit was conducted on 02/25/26 (two visits ordered, one visit conducted). 03/01/26 to 03/07/26 SN visit was conducted on 03/03/26 (two visits ordered, one visit conducted). The clinical record showed no patient refusal of visit, physician notification or change in orders. On 03/13/26 at 10:00 a.m., Staff A stated the SN visits were not conducted as ordered. Patient #6 A review of a POC dated 02/21/26 to 04/21/26 showed orders for SN visit frequency of two times a week for nine weeks. The clinical record showed SN visit during the weeks of: 02/22/26 to 02/28/26 SN visit was conducted on 02/23/26 (two visits ordered, one visit conducted). 03/01/26 to 03/07/26 SN visit was conducted on 03/02/26 (two visits ordered, one visit conducted). The clinical record showed no patient refusal of visit, physician notification or change in orders. On 03/13/26 at 10:25 a.m., Staff A stated the SN visits were not conducted as ordered. Patient #8 A review of a POC dated 02/02/26 to 04/02/26 showed orders for aide visits frequency of two times a week. The clinical record showed no aide visits during the weeks of: 02/02/26 to 02/07/26 no aide visits were conducted (two visits ordered, no visit conducted). 02/08/26 to 02/12/26 no aide visits were conducted (two visits ordered, no visit conducted). The clinical record showed no patient refusal of visit, physician notification or change in orders. On 03/13/26 at 11:00 a.m., Staff A stated: 1.Aide visits should not have been included on the POC. 2.No aide visits were conducted.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of QAPI records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2024 and 2025. On 03/13/26 at 11:20 a.m., Staff A stated: 1.The agency provided PT and OT services to patients in 2024 and 2025. 2.The QAPI meetings in 2024 and 2025 had no PT or OT participation.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure SN visit notes showed interventions and patient response to wound care for one (Patient #4) of nine patients. Findings: Patient #4 A review of a POC dated 01/31/26 to 03/31/26 showed orders for a SN visit frequency of two times a week for nine weeks for SN to perform wound care to the sacrum of cleanse with normal saline, apply calcium alginate and Medi-honey and cover with bordered foam dressing two times a week. A review of the clinical record of SN visits conducted on 02/04/26, 02/11/26, 02/18/26, 02/25/26 and on 03/03/26 showed no documentation of interventions that were performed by the nurse during the visits and showed no patient response to the interventions. On 03/13/26 at 10:10 a.m., Staff A stated the SN visit notes did not document what the nurse did and how the patient tolerated the treatments.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/11/23 to 01/12/23. Standard 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), §485.542(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 a community-based risk assessment (All Hazards Risk Assessment) was developed and implemented for all patients and employees. Findings: A review of administrative records showed no community-based risk assessment for the agency, its patient population, or its employees. On 01/12/22 at 1:00 p.m., Staff A stated the agency did not have a community-based risk assessment developed and implemented for the agency.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of administrative records showed no administrative processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency were in place. On 01/12/22 at 1:00 p.m., Staff A stated the agency did not have Emergency Preparedness Plan administrative processes for an integrated emergency preparedness response in place.

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 emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted and properly documented for calendar years 2021 and 2022 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for calendar years 2021 (documentation showed an entry dated 06/15/21 of mock drill for tornado response but showed no documentation of what the drill entailed, staff participation and showed no after action response summary detail report); and 2022 (documentation showed a EP drill was activated on 05/15/22 from 8p.m. until 8:05 p.m. [5 minutes] but showed no documentation of what the drill entailed and showed no after action response summary detail report). On 01/12/23 at 1:00 pm, Staff A stated: 1. The agency had no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for and 01/01/21 to 06/14/21 and 06/16/21 to 12/31/21 calendar year and 01/01/22 to 05/14/22; 05/16/22 to 12/31/22 calendar year and; 2. EP plan drills documented for 06/14/21 and 05/15/22 showed no documentation of what the drills entailed, showed no staff participation and showed no after action response summary detail reports.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 01/11/23 to 01/12/23. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Condition level deficiencies were cited in the following areas: 484.60 Care planning, Coordination of services, Quality of care 484.65 Quality Assessment and Performance Improvement 484.70 Infection Prevention and Control Glossary: CHHA certified home health aide EP Emergency Preparedness HHA Home Health Agency PIP Performance Improvement Project POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure the patients’ right to participate in the establishment and revision of a plan of care and be informed of disciplines to provide services with expected frequencies of visits after comprehensive assessments for two (Patients #4 and #5) of seven patients. Findings: Patient #4 A review of the clinical record showed no documentation of physician orders (episodic POCs) for POC s for episode period of 10/14/22 to 12/12/22 and the subsequent episode period of 12/13/22 to 02/10/23. Documentation showed no physician notification of the conducted comprehensive OASIS assessment on 10/12/22, documented no physician orders, showed no patient participation in the development of the POC, showed no physician notification of the conducted recertification OASIS assessment on 12/08/22. On 01/12/23 at 11:55 a.m., Staff A stated: 1. Patient #4 did not have a POC (physician orders) for the episode period of 10/14/22 to 12/12/22; 2. Did not have a POC (physician orders) for the episode period of 12/13/22 to 02/10/23 and; 3. Documentation showed no patient participation in the development of a POC for either certification (episode) period. Patient #5 A review of the clinical record showed no documentation of physician orders (episodic POCs) for POC s for episode period of 10/13/22 to 12/11/22 and the subsequent episode period of 12/12/22 to 02/09/23. Documentation showed no physician notification of the conducted comprehensive OASIS assessment on 10/13/22, documented no physician orders and showed no patient participation in the development of the POC; and showed no physician notification of the subsequent recertification OASIS assessment conducted, documented no physician orders and showed no patient participation in the development of the POC. On 01/12/23 at 12:00 p.m., Staff A stated: 1. Patient #5 did not have a POC (physician orders) for the episode period of 10/13/22 to 12/11/22; 2. Did not have a POC (physician orders) for the episode period of 12/12/22 to 02/09/23 and; 3. Documentation showed no patient participation in the development of a POC for either certification (episode) period.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of an episodic Plan of Care after a comprehensive OASIS assessment for two (Patients #4 and #5) of seven patients. The failed practice prevented the patient from participating in the planning of services and receiving care to achieve functional and physical health improvements for all patients. See tag G572. Based on record review and interview, the agency failed to ensure individualized patient POC included weight reporting parameters for two (Patients #1 and #6) of seven patients. The failed practice had the potential to affect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. See tag G574. Based on record reviews and interview, the agency failed to ensure SN visits were ordered by the physician for two (Patients #4 and #5) of seven patients. The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services ordered by their physician for all patients. See tag G580. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of an episodic Plan of Care after a comprehensive OASIS assessment for two (Patients #4 and #5) of seven patients. The failed practice prevented the patient from participating in the planning of services and receiving care to achieve functional and physical health improvements for all patients. Findings: Patient #4 A review of the clinical record showed no documentation of physician orders (episodic POCs) for POC s for episode period of 10/14/22 to 12/12/22 and the subsequent episode period of 12/13/22 to 02/10/23. Documentation showed no physician notification of the conducted comprehensive OASIS assessment on 10/12/22, documented no physician orders and showed no physician notification of the conducted recertification OASIS assessment on 12/08/22 . On 01/12/23 at 11:55 a.m., Staff A stated: 1. Patient #4 did not have a POC (physician orders) for the episode period of 10/14/22 to 12/12/22; 2. Did not have a POC (physician orders) for the episode period of 12/13/22 to 02/10/23 and; 3. Received agency services without physician notification and orders. Patient #5 A review of the clinical record showed no documentation of physician orders (episodic POCs) for POC s for episode period of 10/13/22 to 12/11/22 and the subsequent episode period of 12/12/22 to 02/09/23. Documentation showed no physician notification of the conducted comprehensive OASIS assessment on 10/13/22 and documented no physician orders; and showed no physician notification of the conducted recertification OASIS assessment and documented no physician orders. On 01/12/23 at 12:00 p.m., Staff A stated: 1. Patient #5 did not have a POC (physician orders) for the episode period of 10/13/22 to 12/11/22; 2. Did not have a POC (physician orders) for the episode period of 12/12/22 to 02/09/23 and; 3. Received agency services without physician notification and orders.

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 individualized patient POC included weight reporting parameters for two (Patients #1 and #6) of seven patients. The failed practice had the potential to affect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. Findings: Patient #1 A review of the POC dated 12/10/22 to 2/07/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit. Documentation showed SN visits were conducted on 12/14/22, 12/21/22, 12/28/22 and on 01/04/22 and showed no patient weight monitoring was conducted. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. Patient #6 A review of the POC dated 11/29/22 to 1/27/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit. Documentation showed SN visits were conducted on 12/05/22, 12/12/22 and on 12/19/22 and showed no patient weight monitoring was conducted. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 01/12/23 at 12:15 p.m., Staff A stated POCs for patients #1 and #6 should have included weight reporting parameters for physician notification.

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 reviews and interview, the agency failed to ensure SN visits were ordered by the physician for two (Patients #4 and #5) of seven patients. The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services ordered by their physician for all patients. Findings: Patient #4 A review of the clinical record showed no documentation of physician orders for POC episode period of 12/13/22 to 2/10/22. Documentation showed SN visits were conducted on 12/13/22, 12/20/22, 12/27/22 and on 01/06/23 (four SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 01/12/23 at 11:55 a.m., Staff A stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN visits were conducted without orders for patient #4. Patient #5 A review of the clinical record showed no documentation of physician orders for POC episode periods of 10/13/22 to 12/11/22 and 12/12/22 to 2/09/23. Documentation showed SN visits were conducted on 11/03/22, 11/10/22, 11/17/22, 11/24/22, 12/01/22 and on 12/01/22 (six SN visits conducted, no visits ordered [no episodic POC]); and on 12/15/22, 12/22/22, 12/29/22 and on 01/05/23 (four SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 01/12/23 at 12:00 p.m., Staff A stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN visits were conducted without orders for patient #5.

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 show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients 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 show conduction of patient centered QAPI Program activities for all patients and 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 calendar years 2020, 2021 and 2022 for all patients and employees. The 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 plan and activities for all patients and employees. The 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 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 show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: Review of administrative records of a patient centered QAPI program for the agency showed no data utilized in the agency's QAPI Program for calendar years 2020, 2021 and 2022. Additional administrative records were requested. No additional records were provided. On 01/12/23 at 11:00 a.m., Staff B stated there was no documentation which showed the utilization of data in the conduction of QAPI Program activities for calendar years 2020, 2021 and 2022.

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 show conduction of patient centered QAPI Program activities for all patients and 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: Administrative records were reviewed and showed no conduction of patient centered QAPI Program activities to improve the care, services, and operations of the agency for calendar years 2020, 2021 and 2022. Documentation showed a check marked list format of quarterly QA committee meetings in calendar years 2020, 2021 and 2022 but showed no data, no data collection sources, no data analysis, no identification of issues or problems and showed no agency interventions or subsequent follow up of interventions. Additional administrative records were requested. No additional records were provided. On 01/12/23 at 11:00 a.m., Staff B stated there was no documentation which showed the conduction of a patient centered QAPI Program activities for calendar years 2020, 2021 and 2022 that showed data, data collection sources, data analysis, identification of issues or problems by the agency or showed agency interventions and subsequent follow up of interventions.

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 calendar years 2020, 2021 and 2022 for all patients and employees. The 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: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of a QAPI program PIP for calendar years 2020, 2021 and 2022 were requested. Additional administrative records were requested. No records were provided. On 01/12/23 at 11:00 a.m., Staff B stated there was no documentation of ongoing QAPI program PIPs for calendar years 2020, 2021 and 2022.

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 plan and activities for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: Administrative records were reviewed and showed no governing body oversite of the conduction of a patient centered QAPI Program plan and activities for calendar year 2020 and no QAPI program data and related activities for calendar years 2021 and 2022. Additional administrative records were requested. No additional records were provided. On 01/12/23 at 11:15 a.m., Staff A stated there was no documentation which showed governing body oversite of the conduction of patient centered QAPI Program plan and activities for calendar year 2020 and no QAPI program data and related activities for calendar years 2021 and 2022.

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: Based on record review and interview, the agency failed to ensure its infection control program included surveillance, monitoring and reporting and was included in QAPI program activities for all patients and staff. The failed practice placed the agency at risk for missed opportunities to identify and reduce the incidence and occurrence of infection throughout the agency and effect the health and well-being of all patients and employees. See tag 684. Based on record review and interview, the agency failed to show infection control education was: 1) Included in QAPI activities and; 2) Was provided and/or maintained for all patients and employees. The failed practice placed the agency at risk for missed opportunities to identify and correct substandard practices and reduced opportunities to create learning throughout the agency for all patients and employees. See tag G 686. .

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 its infection control program included surveillance, monitoring and reporting and was included in QAPI program activities for all patients and staff. The failed practice placed the agency at risk for missed opportunities to identify and reduce the incidence and occurrence of infection throughout the agency and effect the health and well-being of all patients and employees. Findings: Administrative records were reviewed. Documentation showed no infection control program surveillance, monitoring or reporting was included in QAPI program activities for calendar years 2020, 2021 and 2022. Additional administrative records, to include agency infection surveillance and reporting patient logs, employee exposure logs and/or infection control program reports submitted to the governing body for calendar years 2020, 2021 and 2022 were requested. No additional records were provided. On 01/12/23 at 11:00 a.m., Staff B stated there was no documentation which showed the agency’s infection control program, and its surveillance data was included in QAPI program activities for calendar years 2020, 2021 and 2022.

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: Based on record review and interview, the agency failed to show infection control education was: 1) Included in QAPI activities and; 2) Was provided and/or maintained for all patients and employees. The failed practice placed the agency at risk for missed opportunities to identify and correct substandard practices and reduced opportunities to create learning throughout the agency for all patients and employees. Findings: A review of administrative records showed no documentation infection control program education or learning activities were included in QAPI program activities or were provided and maintained for patients and employees of the agency. On 01/12/23 at 11:00 a.m., Staff B stated there was no documentation which showed the agency’s infection control program education was included in QAPI program activities for calendar years 2020, 2021 and 2022. At 1:30 p.m., Staff A stated there was no documentation infection control program education or learning activities were provided by the agency for patients and employees.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the POC for: 1. SN to conduct assessment of patient weight every visit for two (Patients #1 and #7) of seven patients and; 2. SN to conduct visit frequencies as ordered by the physicians for three (Patients #2, 3 and #7) of eight patients. Findings: Patient #1 A review of the POC dated 12/10/22 to 02/07/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit. Documentation showed no assessment and monitoring of the patient’s weight was conducted during SN visits on 12/14/22, 12/21/22, 12/28/22 and on 01/04/23. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 01/12/23 at 11:30 a.m., Staff A stated the SN should have conducted assessment and monitoring of the patient’s weight every visit as ordered by the physician. Patient #2 A review of the POC dated 11/25/22 to 01/23/23 showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed during the weeks of 11/25/22 to 11/26/22 (one visit ordered, one visit missed); 11/27/22 to 12/03/22 (one visits ordered, one visit missed); 12/04/22 to 12/10/22 (one visit ordered, one visit missed); 12/11/22 to 12/17/22 (one visit ordered, one visit missed); 12/18/22 to 12/24/22 (one visit ordered, one visit missed); 12/25/22 to 12/31/22 (one visit ordered, one visit missed) and 01/01/23 to 01/07/23 (one visit ordered, one visit missed). Documentation showed no patient/caregiver refusal of SN visits, no physician notifications and no change in orders. On 01/12/23 at 11:35 a.m., Staff A stated the SN visit frequency should have been conducted and documented as ordered by the physician. Patient #3 A review of the POC dated 11/29/22 to 01/23/23 showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed during the weeks of 12/11/22 to 12/17/22 (one visit ordered, one visit missed); 12/18/22 to 12/24/22 (one visit ordered, one visit missed); 12/25/22 to 12/31/22 (one visit ordered, one visit missed); and 01/01/23 to 01/07/23 (one visit ordered, one visit missed). Documentation showed no patient/caregiver refusal of SN visits, no physician notifications and no change in orders. On 01/12/23 at 11:45 a.m., Staff A stated the SN visit frequency should have been conducted and documented as ordered by the physician. Patient #6 A review of the POC dated 11/29/22 to 01/27/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit. Documentation showed no assessment and monitoring of the patient’s weight was conducted during SN visits on 12/08/22, 12/12/22 and on 12/19/23. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 01/12/23 at 12:15 p.m., Staff A stated the SN should have conducted assessment and monitoring of the patient’s weight every visit as ordered by the physician. Patient #7 A review of the POC dated 09/16/22 to 11/14/22 showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed no SN visits were conducted during the episodic certification period and the patient was discharged to hospice provider services on 10/24/22 (six visits ordered no visits conducted). Documentation showed the last documented SN visit was dated 09/02/22 with a recertification OASIS assessment dated 09/12/22. Documentation showed no patient/caregiver refusal of SN visits, no physician notifications and no change in orders. On 01/12/23 at 12:15 p.m., Staff B stated the SN visit frequency should have been conducted visits and documented visits and care as ordered by the physician.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided to a receiving service provider for one (Patients #7) of seven patients. Findings: Patient #7 A review of the clinical record documented discharge from the agency on 10/24/22 to hospice services. Documentation showed no discharge summary was provided to the hospice service provider. On 01/12/23 at 12:15 p.m., Staff A stated no discharge summary was sent to the receiving service provider for patient #7.