Every finding on record at Healthcomp Ltd

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/03/24 and 12/04/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 12/03/24 and 12/04/24. 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 Staff A and B were identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff A and C. Deficiencies were cited as a result of the re-certification survey. GLOSSARY: CHHA Certified Home Health Aide DME Durable Medical Equipment GU Genitourinary LPN Licensed Practical Nurse OASIS Outcome and Assessment Information Set POC Plan of Care RN Registered Nurse Pt/Pts Patient/Patients SN Skilled Nurse QAPI Quality Assessment and Performance Improvement VS Vital Signs

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was performed within 48 hours of the referral for one (Pt #4) of seven patients reviewed. Findings: Pt #4 A review of the clinical record showed a patient referral dated 10/31/24. Documentation showed an initial patient assessment and SOC dated 11/4/24 (four days later). Documentation showed no physician or patient request to delay the initial assessment. On 12/05/24 at 12:30 pm, Staff A stated the initial assessment for Pt #4 was not within 48 hours of the referral and she had no documentation as to why the admission was four days after the referral.

Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to an OASIS was completed for one (Pt #1) of seven patients. Findings: Pt #1 A review of an OASIS recertification assessment dated 10/23/24 the form was incomplete and the following items were left blank: Episode Timing, VS, Past Medical History, Most Recent Immunizations, Health Screening, Advanced Directives, Functional Limitations, Sensory Status, Mental Status, Community Agencies/Social Service Screening, Safety Measures, Fire Assessment for Patients with Oxygen, Activities Permitted, Musculoskeletal, Fall Risk Assessment Tool, Self Care, Mobility, GU, Digestive, Pain Scale, Endocrine, Cardiovascular, Nutrition, Physician's Orders of Diet Requirements, Pressure Ulcer/Injury Risk, Integumentary Status, Medication, Orders for Discipline and Treatments, Patient Strengths, Conclusions, Skilled Intervention, and Visit Assessment. On 12/05/24 at 12:22 pm, Staff A stated the document was not completed.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an individualized POC to was developed for one (Pt #1) of seven patients. Findings: Pt #1 A review of a Plan of Care dated 10/27/24 to 12/25/24 showed an incomplete POC. The POC did not include the Primary Diagnosis, Secondary/Other Diagnosis, Advanced Directives, Mental Status, DME & Supplies, Services/Frequency, Prognosis, Safety Measures, Nutritional Requirements, Functional Limitations, Other, Activities, Rehabilitation Potential, Goals and Outcomes, Patient risk for ED and hospital re-admission, and Patient-Specific Interventions and education. On 12/04524 at 2:22 pm, Staff A stated the document was saved without being completed.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a POC for one (Pt #2) of seven patients. Findings: Pt #2 A review of the electronic medical record showed POC not started for the certification period 05/07/24 - 07/05/24. On 10/30/24 at 12:24 pm, Staff A stated the POC for Pt #2 had not been completed.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure preparation and availability of a clinical notes for three (Pt #1, 3 and %) of seven patients. Findings: Pt #1 A review of the electronic medical record showed a SN visit saved for the date of 10/28/24 but no SN note completed. Pt #3 A review of the electronic medical record showed a SN visit saved for the date of 11/26/24 but no SN note completed. Pt #5 A review of the electronic medical record showed SN visits for the dates of 10/17/24 and 10/31/24 the SN notes were not completed. On 12/05/24 at 12:22 pm, Staff A stated the visit notes for Pt #1, 3 and 5 SN visit notes were not completed within 48 hours of the visit.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an LPN supervisory visit for one (Pt #3) of seven patients. Findings: Pt #3 A review of POC dated 10/17/24 - 12/15/24 showed a SN visit frequency of every other week for nine weeks. A review of the clinical record showed LPN visits dated on 10/17/24, 10/30/24, 11/13/24, 11/26/24. Documentation showed no LPN supervisory visits completed 11/13/24 as scheduled in the electronic medical record for certification period 10/17/24 - 12/15/24 and no additional supervisory visits though 12/05/24. On 12/11/24 at 12:24 p.m., Staff A stated the LPN supervisory visit should have been completed but the nurse is behind on her documentation.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Pt #3) of one patient with home health aide services. Findings: Patient #3 A review of a POC dated 10/17/24 - 12/15/24 showed a home health aide visit frequency of once a week for nine weeks. A review of the clinical record showed CHHA visits dated on 10/18/24, 10/25/24, 11/01/24, 11/08/24, 11/22/24, and 11/26/24. Documentation showed no supervisory visits completed from 10/17/24 - 12/05/24 (49 days without a supervisory visit). On 12/05/24 at 12:22 p.m., Staff A stated the CHHA supervisory visits should have been completed every 14 days.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body provided oversight of the QAPI program for 94 current patients and all employees. Findings: A review of administrative records showed no governing body approval of the QAPI program or QAPI activities from 03/29/2023 - 11/11/24. On 12/04/24 at 12:15 pm, Staff A stated the governing body did not show approval of the QAPI program from 03/29/2023 - 11/11/24.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program Survey at the agency on 02/01/22. Deficiencies were cited as a result of the Emergency Preparedness survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure maintenance and update of an emergency preparedness plan for calendar years 2020 and 2021 for all agency patients and staff. A review of emergency preparedness records for 2019, 2020 and 2021 showed no update or review of the emergency plan for calendar years 2020 and 2021. On 02/01/22 at 2:46 pm, Staff A stated: 1) the agency had not updated their emergency preparedness program records for 2020 and 2021 and 2) emergency preparedness records didn't show a review of the program since calendar year 2019.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness plan testing was conducted for all agency patients and staff. A review of emergency preparedness program records showed no testing of the agency's emergency plan, no exercises, no tabletop exercise and no documentation of testing based on actual, local or state emergencies or activities for calendar years 2020 or 2021. Documentation showed no testing of the emergency plan since calendar year 2019. On 02/01/22 at 2:47 pm, Staff A stated they were behind on their documentation of emergency preparedness activities and their testing exercises were not shown in their current records.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/01/22. An entrance conference was conducted with Staff A. Staff A and M were identified as the contact persons for clinical and administrative issues. The survey process was explained. Questions were answered. Findings were discussed during an informal exit conference by phone with Staff M. Standard level deficiencies were cited as a result of the re-certification survey. GLOSSARY POC Plan of Care QAPI Quality Assessment and Performance Improvement PIPs Performance Improvement Projects Pt Patient

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 a POC for one (patient #4) of seven patients. Patient #4 A review of the clinical record showed patient began home health services with the agency on 12/10/21. Clinical documentation showed no POC. A review of the electronic medical record showed: 1) the status of the POC as "not started" (other than the document title and date, there was no document to access); 2) missed visit notes documented by SN for 12/17/21, 12/20/21, 12/24/21, 12/31/21; 3) a non billable discharge on 01/10/22 shown as, "not started." On 02/01/21 at 2:30 m, Staff A stated; 1) "Not started" meant the visit was made but documentation had not begun and 2) they were aware that the POC had not been developed.

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 QAPI documentation was available and able to show measurable improvements in identified indicators and measurements, analysis and tracking of identified indicators for all agency patients on service during 2020 and 2021. A review of QAPI records for calendar years 2020 and 2021 showed no ongoing QAPI data compiled, accumulated, measured, analyzed or consistently tracked. On 02/01/2022 at 2:45 pm, Staff A stated: 1) They were not expecting the survey until March and thought they had more time to gather documentation; 2) They were behind on documentation due to the COVID pandemic and staff shortages; 3) They had taken QAPI documentation home to organize and didn't have immediate access to it at this survey.

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 program documentation was capable of showing utilization of OASIS data included in QAPI activities for all patients on service during calendar years 2020 and 2021. A review of QAPI records for calendar year 2020 and 2021 showed no OASIS data and no routine collection of other patient data for inclusion, identification, review or implementation of corrective measures. On 02/01/22 at 2:45 pm, Staff A stated: 1) They were not expecting the survey until March and thought they had more time to gather QAPI documentation; 2) They were behind on documentation due to the COVID pandemic and staff shortages; 3) They had taken QAPI documentation home to organize and didn't have immediate access to it at this survey.

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 conduction of PIPs for all patients and agency staff during calendar years 2020 and 2021. A review of QAPI records showed no identification, conduction or evaluation of PIPs for calendar years 2020 and 2021. On 02/01/22 at 2:50 pm, Staff A stated they had no PIPs.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical notes were completed and included in the clinical record for 4 (patients #2, 3, 5 and 7) of seven patients. Patient #2 A review of the clinical record showed an episode period of 11/13/21-01/11/2 and POC orders for SN visits every other week for nine weeks. A review of nursing visit notes showed a recertification dated 01/08/22 documented as "not started." Patient #3 A review of the clinical record showed an episode period of 12/25/1-02/22/22 and POC orders for SN visits every other week for nine weeks. A review of nursing visit notes showed a visit dated 01/20/22 documented as "not started." Pt #5 A review of the clinical record showed an episode period of 01/09/22-03/09/22 and POC orders for SN visits once a week for 10 weeks. A review of nursing visit notes showed visits dated 01/09/22 and 01/26/22 as "not started." Pt #7 A review of the clinical record showed an episode period of 12/22/21-02/19/22 and POC orders for SN visits once a week for nine weeks. A review of nursing visit notes showed a visit note dated 01/19/22 as "not started." On 02/01/22 at 2:55 pm, Staff A stated the visits were completed but the all visit documentation (assessment and visit notes) had not been completed in the electronic medical records for patients #2, 3, 5 and 7.