Every finding on record at Harmon County Health Care Authority

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/01/23 to 03/02/23. A deficiency was cited as a result of the Medicare Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(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 development of a community-based risk assessment (All Hazards Risk Assessment) for 38 patients and all employees. A review of administrative records showed no community-based risk assessment which addressed the agency, its patient population, or its employees for the calendar years of 2021, 2022 and January 01, 2023, to March 02, 2023. On 03/02/23 at 1:10 pm, Staff A stated there was no all hazards risk assessment for the calendar years of 2021, 2022 and January 01, 2023, to March 02, 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/01/23 to 03/02/23. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. The following condition level deficiencies were cited as a result of the re-certification survey: 484.65 Quality Assessment/Performance Improvement 484.70 Infection Prevention and Control GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects 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 skilled nurse frequencies showed the duration of visits for six (Patients #1, 3, 4, 5, 6 and 7) of seven patients. Patient #1 A plan of care dated 11/11/22 to 01/09/23 showed a skilled nurse frequency of one visit per week with no duration. Patient #3 A plan of care dated 11/03/22 to 01/01/23 showed a skilled nurse frequency of one visit per week with no duration. Patient #4 A plan of care dated 10/25/22 to 12/23/22 showed a skilled nurse frequency of one visit per week with no duration. Patient #5 A plan of care dated 11/22/22 to 01/20/23 showed a skilled nurse frequency of two visits per week with no duration. Patient #6 A plan of care dated 12/18/22 to 02/15/23 showed a skilled nurse frequency of one visit per week with no duration. Patient #7 A plan of care dated 12/23/22 to 02/20/23 showed a skilled nurse frequency of one visit per week with no duration. On 03/02/23 at 11:35 am, Staff A stated the plan of care for Patients #1, 3, 4, 5, 6 and 7 should have documented the duration on the skilled nurse frequency.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse notified the physician of pain ratings outside of ordered parameters for one (Patient #1) of seven patients. Patient #3 A review of the plan of care dated 11/11/22 to 01/09/23 showed a skilled nurse frequency of one visit per week and documented the physician to be notified of pain ratings greater than five. A review of the clinical record showed the following: A skilled nurse assessment dated 11/17/22 with a pain rating of 7 out of 10 on the classic 1-10 pain scale. No documentation of notification to the physician of the pain rating. A skilled nurse assessment dated 11/28/22 with a pain rating of 6 out of 10 on the classic 1-10 pain scale. No documentation of notification to the physician of the pain rating. A skilled nurse assessment dated 12/11/22 with a pain rating of 7 out of 10 on the classic 1-10 pain scale. No documentation of notification to the physician of the pain rating. A skilled nurse assessment dated 01/05/23 with a pain rating of 7 out of 10 on the classic 1-10 pain scale. No documentation of notification to the physician of the pain rating. On 03/02/23 at 11:10 am, Staff A stated the skilled nurse should have notified the physician of elevated pain ratings.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care with physical therapy for one (Patient #2) of seven patients. Patient #2 A review of the plan of care dated 12/10/22 to 02/07/23 showed a primary diagnosis of chronic obstructive pulmonary disease. A review of physical therapy plan of care dated 12/15/22 showed a primary diagnosis of hypertensive hearth disease. On 03/02/23 at 11:35 am, Staff A stated the agency failed to show proper coordination of care in relation to the primary diagnosis for Patient #2.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program for all patients and employees. This failed practice had the potential to place 38 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See G642. Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place 38 patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See G644. Based on record review and interview, the agency failed to ensure improvement activities were identified and focused on high-risk problem-prone areas for 38 current patients. This failed practice had the potential to place 38 current patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. See G648 Based on record review and interview, the agency failed to ensure conduction of a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. The failed practice had the potential to place 38 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See G656. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 38 patients and all employees. This failed practice had the potential to place the agency, all patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See G658. Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. This failed practice had the potential to place all 38 patients and employees at risk for insufficient governing body oversite of agency services and operations. See G660 for details.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program for all patients and employees. This failed practice had the potential to place 38 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency for 2021, 2022 and January 1, 2023 through March 02, 2023. On 03/02/23 at 12:50 pm, Staff A stated there was no documentation of a QAPI program for 2021, 2022 and no current documentation of a QAPI program for 2023.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place 38 patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for calendar years of 2021, 2022 and from January 01, 2023, to March 02, 2023. On 03/02/23 at 12:50 pm, Staff A stated they had no analysis of data collected available that showed improved quality of patient care and program improvement data was not available for 2021, 2022 and from January 01, 2023, to March 02, 2023.

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure improvement activities were identified and focused on high risk problem-prone areas for 38 current patients. This failed practice had the potential to place 38 current patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. A review of administrative records showed a plan for a QAPI Program with no record of data utilization or improvement efforts for 2021, 2022 and from January 01, 2023, to March 02, 2023. On 03/02/23 at 12:50 pm, Staff A stated there was no documentation of the QAPI program for 2021, 2022 and from January 01, 2023, to March 02, 2023.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. The failed practice had the potential to place 38 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency for calendar years 2021, 2022 and January 01, 2023, to March 02, 2023. On 03/02/23 at 12:50 pm, Staff A stated they had no QAPI documentation for calendar years 2021, 2022 and January 01, 2023 to March 02, 2023.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 38 patients and all employees. This failed practice had the potential to place the agency, all 38 patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. A review of QAPI records showed no initiation, review, data analysis, or status of PIPs for the calendar years of 2021, 2022 and January 01, 2023, to March 02, 2023. On 03/02/23 at 12:50 pm, Staff A stated the agency had no documented PIP activities for 2021, 2022 and from January 01, 2023, to March 02, 2023.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. This failed practice had the potential to place all 38 patients and employees at risk for insufficient governing body oversite of agency services and operations. A review of administrative records showed no governing body oversite of ongoing QAPI program activities, no patient record audits and no QAPI meetings to improve the care, services and operations of the agency for calendar years 2021, 2022 or for January 01, 2023, to March 02, 2023. On 03/02/23 at 12:50 pm, Staff A stated they had no documentation which showed governing body oversite of QAPI program activities for calendar years of 2021, 2022 or for January 01, 2023, to March 02, 2023.

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: 1) The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency; and 2) The Infection Control Program was included in QAPI activities. This failed practiced placed the agency at risk for missed opportunities to identify and correct substandard practices and reduced opportunities to create learning throughout the agency for 38 patients and employees. See G684. Based on record review and interview, the agency failed to ensure infection control education was: 1) included in QAPI activities; 2) showed interventions to reduce future infections; and 3) provided and/or maintained for current employees. This failed practiced placed the agency at risk for missed opportunities to identify and correct substandard practices and reduced opportunities to create learning throughout the agency. See G686.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1) The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency; and 2) The Infection Control Program was included in QAPI activities. This failed practiced placed the agency at risk for missed opportunities to identify and correct substandard practices and reduced opportunities to create learning throughout the agency for 38 patients and employees. A review of administrative records showed no ongoing infection control program for the agency or infection control surveillance data for calendar year 2021, 2022 and January 1, 2023, to March 02, 2023. On 03/02/23 at 12:55 p.m., Staff A stated: 1) The agency had no documented infection control program or infection control program surveillance activities for calendar year's 2021, 2022 and January 1, 2023, to March 02, 2023.; and 2) The agency should have infection control data as part of their comprehensive infection control program.

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 ensure infection control education was: 1) included in QAPI activities; 2) showed interventions to reduce future infections; and 3) provided and/or maintained for all employees and 38 current patients. This failed practiced 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 employees and patients. A review of administrative records showed no evidence of infection control program learning activities provided by the agency. A request for infection control documents, Infection Control Program records, QAPI records, and personnel records yielded no additional records for 2021, 2022 and for January 01, 2023, to March 02, 2023. On 03/02/23 at 12:55 pm, Staff A stated there was no documentation of an infection control program for 2021, 2022 and for January 01, 2023 to March 02, 2023.