Every finding on record at Impressions Home Health Care Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/15/25 to 01/17/25. 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 from 01/15/25 to 01/17/25. An entrance conference was conducted with Staff A, B, C and D. The survey process was explained. Questions were answered. Staff A was identified as a contact person for administrative and clinical issues, and Staff B was identified as an additional contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, C, D, E, F and G. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary EMR electronic medical record HHA Home Health Agency HHCOC home health change of care PIP performance improvement project POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse SOC start of care

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notice were provided to three (Patients #15, 16 and 17) of 17 patients. Findings: Patient #15 A review of the clinical record showed no advance notice of discharge, home health change of care notice, or physician communications prior to discharge from the agency on 12/06/24 for no insurance authorization for services. On 01/17/25 at 2:32 p.m., Staff A stated there were no ABN or HHCOC notices in the clinical record or physician communications prior to the patient being discharged from the agency for no insurance authorization for services. Patient #16 A review of the clinical record showed no advance notice of discharge, or home health change of care notice, or physician communications prior to discharge from the agency on 09/25/24 for insurance denial for payment of services. On 01/17/25 at 2:37 p.m., Staff A stated there were no ABN or HHCOC notices in the clinical record or physician communications prior to the patient being discharged from the agency for insurance denial for payment of services. Patient #17 A review of the clinical record showed no advance notice of discharge, home health change of care notice, or physician communications prior to discharge from the agency on 09/05/24 for refusal of services. On 01/17/25 at 2:37 p.m., Staff A stated there were no ABN or HHCOC notices in the clinical record or physician communications prior to the patient being discharged from the agency for refusal of services.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to: 1. Educate the patient on potential health outcomes related to refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance and; 2. Notify the physician of the patient's continued refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance for one (Patient #17) of 17 patients. Findings: Patient #17 A review of a POC for 08/07/24 to 10/05/24 showed a SN visit frequency of one time a week for three weeks, then one time a month for two months. A review of visit notes showed missed SN visits on 08/15/24 and 08/23/24 and showed a desk discharge for patient refusal of visits on 09/05/24. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of and/or missed SN visits and no documentation of follow up communications to the physician of the patient's continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance. On 01/17/25 at 2:39 p.m., Staff A stated documentation showed no: 1. Attempts to educate the patient of potential health outcomes related to refusal of and/or missed SN visits and; 2. No physician notification of the patient's continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance.

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 a SOC assessment was conducted within 48 hours of referral for six (Patients #9, 11 and #12) of 17 patients. Findings: Patient #9 A review of the clinical record showed the agency received referral information on 11/08/24 and the SOC assessment occurred on 11/12/24 (4 days). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #11 A review of the clinical record showed the agency received referral information on 11/18/24 and the SOC assessment occurred on 11/21/24 (3 days). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #12 A review of the clinical record showed the agency received referral information on 09/11/24 and the SOC assessment occurred on 09/16/24 (5 days). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 01/17/25 at 2:06 p.m. to 2:20 p.m., Staff A stated the SOC assessments for patients #9, 11 and #12 should have been conducted within 2 days of referral or the SOC date ordered by the physician provider.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile was updated for ordered medications for one (Patient #7) of 17 patients. Findings: Patient #7 A review of the clinical record POC dated 11/10/24 to 01/08/25 showed the patient was taking Cipro (an antibiotic) 500 mg twice daily by mouth. The medication profile showed no medication end date. Documentation showed no follow up review or update to the medication profile by the SN. Documentation showed no physician notifications, and no change in orders. On 01/17/25 at 1:50 p.m., Staff A stated documentation showed no follow up review or update to the medication profile by the SN.

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: 1. SN intervention for assessment and instruction for management of pain and pain reporting parameters to report to the physician for nine (Patients #1, 2, 3, 4, 6, 7, 10, 11 and #12) of 17 patients. 2. SN intervention for assessment and instruction for management of blood sugar levels and blood sugar reporting parameters to report to the physician for one (Patients #1) of 17 patients. 3. SN intervention for assessment, instruction and interventions for wound management for wound care site for one (Patient #9) of 17 patients. 4. SN intervention for assessment and instruction for management of weight and weight reporting parameters to report to the physician for one (Patients #10) of 17 patients. 5. Goals for SN assessment, instructions and interventions for: pain management for four (Patients #7, 9, 10 and #12) of 17 patients and; weight management for one (Patient #10) of three patients. Findings: Patient #1 A review of the POC dated 12/10/24 to 02/07/25 showed orders for SN to assess and instruct the patients’ blood sugar and pain level every visit. Documentation showed no assessment of the patients’ blood sugar or pain level during SN visits dated 12/16/24, 12/23/24, 12/30/24 and on 01/06/25. POC documentation identified no physician reporting parameters for the patient's blood sugar or pain levels. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 1:30 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patient's blood sugar or pain levels. Patient #2 A review of the POC dated 12/18/24 to 02/15/25 showed orders for SN to assess and instruct the patient's pain level every visit. Documentation showed a patient reported pain level of 3 during SN visits dated 12/23/24 and on 12/30/24. POC documentation identified no physician reporting parameters for the patient's pain levels. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 1:35 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels. Patient #3 A review of the POC dated 12/12/24 to 02/09/25 showed orders for SN to assess and instruct the patient's pain level every visit. Documentation showed patient reported pain levels of 2 during SN visits dated 12/16/24, 12/18/24, 12/20/24, 12/23/24, 12/27/24, 12/29/24, 01/01/25 and on 01/06/25. POC documentation identified no physician reporting parameters for the patients’ pain levels. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 1:30 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels. Patient #4 A review of the POC dated 11/23/24 to 01/21/25 showed orders for SN to assess and instruct the patient's pain level every visit. Documentation showed no assessment of the patient's pain levels during SN visits dated 11/26/24, 12/03/24, 12/10/24, 12/18/24, 12/24/24, 01/02/25 and 01/03/25. POC documentation identified no physician reporting parameters for the patient's pain levels. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 1:40 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels. Patient #6 A review of the POC dated 12/16/24 to 02/13/25 showed orders for SN to assess and instruct the patient's pain level every visit. Documentation showed no assessment of the patient's pain levels during SN visits dated 12/16/24, 12/18/24, 12/20/24, 12/23/24,12/30/24, 01/06/25 and 01/08/25. POC documentation identified no physician reporting parameters for the patient's pain levels. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 1:45 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels. Patient #7 A review of the POC dated 11/10/24 to 01/08/25 showed orders for SN to assess and instruct the patient's pain level and conduct wound site care interventions every visit. Documentation showed patients reported pain levels during SN visits dated 11/13/24 of 3, 11/15/24 of 3, 11/20/24 of 3, 11/27/24 of 3, 11/29/24 of 8, 12/02/24 of 5, 12/04/24 of 5, 12/06/24 of 5, 12/11/24 of 5, 12/13/24 of 8, 12/16/24 of 7, 12/23/24 of 7, 12/27/24 of 7, 01/03/25 of 7 and 01/08/25 of 7. POC documentation identified no physician reporting parameters for the patient's pain levels, showed no goals related to pain management; and did not identify a wound site for care interventions. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 1:50 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patient's pain levels, showed no goals related to pain management, and showed no wound site for wound care interventions. Patient #9 A review of the POC dated 11/12/24 to 0/10/25 showed orders for SN to assess and instruct the patient's pain level and conduct wound site care interventions every visit. Documentation showed patient reported pain levels during SN visits dated 11/16/24 of 2, 11/18/24 of 2, 11/22/24 of 3, 11/25/24 of 3, 11/29/24 of 2, 12/02/24 of 3, 12/09/24 of 2, 12/13/24 of 1, 12/16/24 of 1, 12/20/24 of 1, 12/23/24 of 1, 12/27/24 of 1, 12/30/24 of 6, 01/03/25 of 1 and 01/10/25 of 1. POC documentation identified no physician reporting parameters for the patient's pain levels. showed no goals for pain management or weight management for congestive heart, and showed no wound site for care interventions. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 2:06 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels, showed no goals related to pain management or weight management, and showed no wound site for wound care interventions. Patient #10 A review of the POC dated 12/10/24 to 02/07/25 showed orders for SN to assess and instruct the patient's pain level and weight management for (congestive heart failure diagnosis) every visit. Documentation showed patient reported pain levels during SN visits dated 12/13/24 of 2, 12/26/24 of 3. POC documentation identified no physician reporting parameters for the patient's pain levels and showed no goals for pain management or weight management (for congestive heart failure) interventions. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 2:15 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels; and showed no goals related to pain management or weight management interventions. Patient #11 A review of the POC dated 11/21/24 to 01/19/25 showed orders for SN to assess and instruct the patients’ pain level every visit. Documentation showed a patient reported pain level of 2 during SN visits dated 11/22/24. POC documentation identified no physician reporting parameters for the patients’ pain levels. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 2:16 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels. Patient #12 A review of the POC dated 11/15/24 to 01/13/25 showed orders for SN to assess and instruct the patients’ pain level every visit. Documentation showed patients’ reported pain levels during SN visits dated 11/15/24 of 3 and on 11/19/24 of 3. POC documentation identified no physician reporting parameters for the patients’ pain levels and showed no goals related to pain management interventions. Documentation showed no physician notifications and no change in orders. On 01/17/25 at 2:20 p.m., Staff A stated the POC documentation identified no physician reporting parameters for the patients’ pain levels; and showed no goals related to pain management or weight management interventions.

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 quality indicator data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative QAPI records for calendar years 2023 and 2024 showed no quality indicator data collection sources from OASIS reporting utilized in the analysis of data in the agency's QAPI Program. On 01/17/25 at 1:15 p.m., Staff A stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no collection or analysis of quality indicator data from OASIS reporting for calendar years 2023 and 2024.

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 interviews, the agency failed to ensure the required performance improvement project documentation for the agency in calendar years 2023 and 2024 for all patients and employees. Findings: A review of QAPI Program documentation showed no performance improvement project documentation for analysis of the identified PIP problem, included no measurable goals (baseline or threshold levels) and showed no intervention activities or monitoring intervals to analyze the data for calendar years 2023 and 2024. On 01/17/25 at 1:15 p.m., Staff A stated the agency had no QAPI PIP documentation which showed intervention activities, analysis of data, follow up or PIP status designation in calendar years 2023 and 2024.

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 interview, the agency failed to ensure clinical visit documentation was completed for three (Patients #7, 9 and #12) of 17 patients. Findings: Patient #7 A review of the POC dated 11/10/24 to 01/08/25 showed orders for SN to assess and monitor health conditions and perform wound care interventions to multiple wound sites each visit. SN visit notes dated 11/20/24, 11/27/24, 11/29/24, 12/02/24, 12/11/24, 12/13/24, 12/16/24, 12/20/24, 12/23/24 and 12/27/24 documented no wound site interventions performed during the visits. On 01/17/25 at 1:50 p.m., Staff A stated SN clinical visit notes for 11/20/24, 11/27/24, 11/29/24, 12/02/24, 12/11/24, 12/13/24, 12/16/24, 12/20/24, 12/23/24 and 12/27/24 did not document wound site interventions. Patient #9 A review of the POC dated 11/12/24 to 01/10/25 showed orders for SN to assess and monitor health conditions and perform wound care interventions to wound sites each visit. SN visit notes dated 11/22/24, 11/25/24, 12/02/24, 12/06/24, 12/16/24, 12/20/24, 12/23/24, 12/27/24, 12/30/24 and 01/03/25 documented no wound site interventions performed during the visits. On 01/17/25 at 2:06 p.m., Staff A stated SN clinical visit notes for 11/22/24, 11/25/24, 12/02/24, 12/06/24, 12/16/24, 12/20/24, 12/23/24, 12/27/24, 12/30/24 and 01/03/25 did not document wound site interventions. Patient #12 A review of the POC dated 11/15/24 to 01/13/25 showed orders for SN to assess and monitor health conditions and perform wound care interventions to wound sites each visit. SN visit notes dated 11/15/24, 11/22/24, 11/27/24 and 01/03/25 documented no wound site interventions performed during the visits. On 01/17/25 at 2:20 p.m., Staff A stated SN clinical visit notes for 11/22/24, 11/25/24, 12/02/24, 12/06/24, 12/16/24, 12/20/24, 12/23/24, 12/27/24, 12/30/24 and 01/03/25 did not document wound site interventions.

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 interviews, the agency failed to ensure completed transfer/discharge summaries were provided to receiving service providers for two (Patients #13 and #14) of 17 patients. Findings: Patient #13 A review of the clinical record showed transfer from the agency on 12/11/24 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the receiving inpatient hospital provider. Documentation showed the patient was discharged from the agency on 01/01/25, at which time a discharge summary was then provided to the in patient hospital provider on 01/01/25 (21 days later). Patient #14 A review of the clinical record showed discharge from the agency on 10/17/24 to hospice provider services. Documentation showed no discharge summary was provided to the receiving hospice provider. On 01/17/25 at 2:25 p.m., Staff A stated documentation showed no transfer/discharge summary was sent to the receiving providers for patients #13 and #14.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 02/17/22 to 02/18/22. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/17/22 to 02/18/22. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff A and C were identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff A, D and E. Deficiencies were cited as a result of the re-certification survey. GLOSSARY: 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 development of an individualized plan of care for three (Patients #1, 2 and 4) of ten patients. Patient #1 A review of the plan of care dated 10/27/21 to 12/25/21 showed a primary diagnosis of pressure ulcer of right buttock, stage II and documented a skilled nurse frequency of two visits per week for nine weeks. The plan of care documented no interventions, treatments or wound care orders regarding the primary diagnosis. Patient #2 A review of the plan of care dated 11/02/21 to 12/31/21 showed a primary diagnosis of pressure ulcer of sacral region, stage IV and documented a skilled nurse frequency of two visits per week for nine weeks. The plan of care documented no interventions, treatments or wound care orders regarding the primary diagnosis. Patient #4 A review of the plan of care dated 11/12/21 to 01/10/22 showed a primary diagnosis of encephalopathy and documented an occupational therapy frequency of evaluation only. A review of the electronic medical record showed the following: A certified occupational therapy assistant visit dated 11/18/21. A certified occupational therapy assistant visit dated 11/23/21. A certified occupational therapy assistant visit dated 11/30/21. An occupational therapy evaluation was conducted on 12/09/21. No orders for occupational therapy frequencies were received prior to this evaluation. On 02/18/22 at 11:10 am., Staff C stated the plan of care for Patient #1 and 2 did not document wound care orders and treatments in regard to the primary disease process. Staff C stated there were no orders for occupational therapy frequencies prior to 12/09/21 for this certification period.

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 orders for speech therapy were followed for one (Patient #4) of 10 patients. Patient #4 A review of the plan of care dated 11/12/21 to 01/10/22 showed a primary diagnosis of encephalopathy and documented a speech therapy order for evaluation and treatment. A review of the electronic medical record showed no speech therapy evaluation, no refusal of services by the patient or caregiver and no physician order changes. On 02/18/22 at 11:10 am, Staff C stated the orders for speech therapy evaluation for Patient #4 were not followed as ordered for this episode.

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 132 patients and all employees. 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 2020 and 2021. On 02/18/22 at 1:40 pm, Staff A stated they had no QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained for calendar years 2020 and 2021.

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 the Infection Control Program included interventions to reduce future infections and promote learning and preventative measures throughout the agency for all 132 patients and all staff. A review of administrative records showed no ongoing infection control program to reduce future infections and provide preventative measures throughout the agency for calendar year's 2019, 2020 and 2021. On 02/18/22 at 1:40 pm, Staff A stated the agency had no comprehensive infection program in place to reduce future infections and provide preventative measures for 2019, 2020 and 2021.