Every finding on record at Interim Healthcare of Tulsa, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/26/24 to 02/28/24. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

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 an emergency preparedness disaster tabletop exercises or disaster drill were conducted for calendar years 2022 and 2023 for all patients and current staff members. A review of the agency's disaster/emergency preparedness records showed no tabletop exercise or disaster drill for the surveyed agency within the past two years. On 02/28/24 at 12:30 p.m., Staff A stated there was no documentation of an emergency preparedness disaster table-top exercises or drills for 2022 and 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/26/24 to 02/28/24. An entrance conference was conducted with Staff A and B, and by phone C, D and E. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A, B, C and E. A condition level deficiency were cited in the following area: 484.65 Quality Assessment and Performance Improvement Glossary: POC Plan of Care SN Skilled Nurse/Nursing QAPI Quality Assurance and Performance Improvement PIP Performance Improvement Project

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 SN frequencies were followed as ordered for four (Patients #1, 8, 9 and 10) of ten patients. Patient #1 A review of the POC dated 12/12/23 to 02/09/24 showed a SN frequency of three visits per week for eight weeks. A review of the medical record showed the following: A SN missed visit dated 01/23/24 and a SN visit dated 01/26/24, and no other visits for the week of 01/20/24 to 01/26/24. Two SN visits dated 01/30/24 and 02/02/24, and no other visits for the week of 01/27/24 to 02/02/24. A SN missed visit dated 02/06/24 and a SN visit dated 02/08/24, and no other visits for the week of 02/03/24 to 02/09/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #8 A review of the POC dated 10/12/23 to 12/10/23 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed the following: A SN missed visit dated 11/21/23 documented no answer or return call, and no other visits for the week of 10/29/23 to 11/04/23. A SN missed visit dated 12/07/23 documented no answer by phone, and no other visits made for the week of 12/02/23 to 12/08/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #9 A review of the POC dated 10/07/23 to 12/05/23 showed a SN frequency of two visits per week for nine weeks. A review of the medical record showed a SN missed visit dated 11/29/23, and no other visits for the week of 11/25/23 to 01/26/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #10 A review of the POC dated 09/21/23 to 11/19/23 showed a SN frequency of two visits per week for one week, and one visit per week for eight weeks. A review of the medical record showed no SN visits were made for the week of 09/23/23 to 09/29/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. On 02/28/24 at 12:05 p.m., Staff D stated the SN frequencies for Patient #1, Patient #8, Patient #9, and Patient #10 were not met as ordered.

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 utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and current employees. This failed practice had the potential to place all patients and current employees 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 conduction of patient centered QAPI Program activities for all patients and current employees. The failed practice had the potential to place all patients and current employees at risk for poor quality of care due to missed opportunities by the agency to detect and correct problem areas. See G646. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for all patients and current employees. This failed practice had the potential to place the agency, all patients and current 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 current employees. This failed practice had the potential to place all patients and current employees at risk for insufficient oversite of agency services, programs and operations and disregard for acceptable practices and policies and procedures. See 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 ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and current employees. This failed practice had the potential to place all patients and current employees 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 2022 and 2023. On 02/28/24 at 12:20 p.m., Staff A stated there was no QAPI program data utilized for 2022 and 2023.

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 ensure conduction of patient centered QAPI Program activities for all patients and current employees. The failed practice had the potential to place all patients and current employees at risk for poor quality of care due to missed opportunities by the agency to detect and correct problem areas. A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar years 2022 and 2023. On 02/28/24 at 12:20 p.m., Staff A stated there was no QAPI program activities developed for 2022 and 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 all patients and current employees. This failed practice had the potential to place the agency, all patients and current employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. A review of the agency’s PIP project showed no initiation, review, data analysis, or status of PIPs for calendar years 2022 and 2023. On 02/28/24 at 12:20 p.m., Staff A stated there was no PIP project developed for 2022 and 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 current employees. This failed practice had the potential to place all patients and current employees at risk for insufficient oversite of agency services, programs and operations and disregard for acceptable practices and policies and procedures. A review of administrative records showed no governing body oversite of ongoing QAPI program activities and no quarterly QAPI meetings to improve the care, services, and operations of the agency for calendar years 2022 and 2023. On 02/28/24 at 12:20 p.m., Staff A stated there was no QAPI program activities developed for 2022 and 2023 and no documentation of governing body oversite of QAPI program activities.

The Oklahoma State Department of Health conducted an unannounced Medicare complaint (OK00057502) survey at the agency on 08/24/21. 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 B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A. Deficiencies were cited related and unrelated to the Medicare complaint survey. The following condition level deficiency was cited as a result of the complaint survey: 484.65 Quality Assessment/Performance Improvement GLOSSARY: POC Plan of Care Pt Patient Pts Patients QAPI Quality Assessment and Performance Improvement SN Skilled Nurse

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an advance beneficiary notice was provided at least 48 hours prior to discharge from agency services for one (Pt #3) of five patients. Findings: Pt #3 A review of clinical records showed a POC date of 06/03/21 and a discharge date of 07/30/21. Documentation showed no advance notice of discharge provided to the patient prior to the date of discharge 07/30/21. On 08/24/21 at 2:01 pm, Staff B stated Pt #3 did not have an advance beneficiary notice of discharge from the agency.

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 reviewed and updated with an end date for an ordered medication for two (Pt #2 and 4) of five patients. Findings: Pt #2 A review of a POC dated 08/02/21 to 09/30/21 showed an order for silvadene cream and loose gauze, wash and change daily. Documentation showed no update to the medication profile for the medication or a drug interaction check completed. Pt #4 A review of a POC dated 07/20/21 to 09/17/21 an infection control report showed the patient had an order for vancomycin 125 mg 4 tabs daily for 7 days then 2 tabs daily for 7 days then 1 tab daily for seven days. Documentation showed no update to the medication profile for the medication or a drug interaction check completed. On 08/24/21 at 10:00 a.m., Staff B stated the medications ordered during the certification period should have been added to the medication profile and a medication interaction check would have been automatically completed by the software system for Pts #2 and 4.

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 128 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 128 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 128 current patients. This failed practice had the potential to place 128 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 development of performance improvement activities to track adverse patient events. This failed practice had the potential to place 128 current patients at increased risk for avoidable events such as increased falls and secondary infections. See (G654)

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 128 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency from January 1, 2021 through August 24, 2021. Requests for QAPI records were unmet and the agency was unable to provide documentation or records of the QAPI program from Jauary 1, 2021 to August 24, 2021. On 08/24/21 at 11:43 am, Staff A stated she was unable to provided documentation of a current QAPI program from January 1, 2021 to August 24, 2021.

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 128 patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for January 01, 2021 to August 24, 2021. Requests for data collection activity records were unmet and the agency was unable to provide the requested documentation from January 1, 2021 to August 24, 2021. On 08/24/21 at 11:43 am, Staff A stated she was unable to provide documentation of analysis of data collected that showed improved quality of patient care and program improvement data January 01, 2021 to August 24, 2021.

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 128 current patients. This failed practice had the potential to place 128 current patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. Findings: A review of administrative records showed no plan for a QAPI Program and no record of data utilization or improvement efforts from January 01, 2021 to August 24, 2021. Requests for QAPI records were unmet and the agency was unable to provide documentation or records of the QAPI program from January 1, 2021 to August 24, 2021. On 08/24/21 at 11:43 am, Staff A stated she was unable to provide documentation of the QAPI program from January 01, 2021 to August 24, 2021.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of performance improvement activities to track adverse patient events. This failed practice had the potential to place 128 current patients at increased risk for avoidable events such as increased falls and secondary infections. A review of QAPI and administrative records showed no performance improvement activities. Documentation showed no processes in place for program development or implementation. Requests for performance improvement records were unmet and the agency was unable to provide documentation or records which tracked patient adverse events from January 1, 2021 to August 24, 2021. On 08/24/21 at 11:43 am, Staff A stated she was unable to provide documentation of the QAPI program from January 1, 2021 to August 24, 2021.

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 oversight of the conduction of patient centered QAPI Program activities for all patients and employees. This failed practice had the potential to place all 128 patients and employees at risk for insufficient governing body oversight of agency services and operations. Findings: A review of administrative records showed no governing body oversight of ongoing QAPI program activities, no patient record audits and no QAPI meetings to improve the care, services and operations of the agency from January 1, 2021 to August 24, 2021. On 07/20/21 at 12:41 pm, Staff A stated they had no documentation which showed governing body oversight of QAPI program activities from January 1, 2021 to August 24, 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: 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 for four of four patients reviewed. Findings: A review of administrative records showed "Infection Control Report's" for patients. The reports showed date of infection, patient's name, the date of order, symptoms, type of infection, a place to insert medication orders and another place titled, "follow-up." Documentation showed no follow-up, no resolution, no entry on how the agency was using the data to reduce infections throughout the agency. Documentation showed no employees included in the "Infection Control Report's." No other documentation was recorded and showed no ongoing infection control program for the agency or infection control surveillance data for 01/01/21 to 08/24/21. Infection Control Report for Pt #2 The report noted a medication was ordered 08/09/21 but did not state the name of the medication, the dosage or the number of days the medication was to be taken. The report does not show any follow-up/resolution for the patient to make the determination if the treatment had been effective. Infection Control Report for Pt #3 The report noted the patient was seen in the emergency room with urinary symptoms on 07/18/21 with a urinalysis completed and the patient prescribed Cipro 250 mg twice a day for 5 days. The report does not show any follow-up/resolution for the patient to make the determination if the treatment had been effective. Infection Control Report for Pt #4 The report noted gastrointestinal symptoms and a stool specimen and blood were obtained for testing (no documentation of which tests). The report does not give a diagnosis but does show vancomycin 125 mg 4 tabs daily for 7 days then 2 tabs daily for 7 days and then 1 tab daily for 7 days. The report does not show any follow-up/resolution for the patient to make the determination if the treatment had been effective. Additional infection control surveillance documentation for patients and staff was requested and yielded no further reports. On 08/24/21 at 2:01 pm, Staff B stated he had no other infection or QAPI documentation available to provide.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/29/21 to 03/31/21. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

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 an emergency preparedness disaster table top exercises and drills were conducted for calendar year 2019 for 238 patients and all staff members. Findings: A review of administrative records related to emergency preparedness showed no agency disaster table top exercises, drills or participation in community based drills for calendar year 2019. On 03/31/21 at 12:30 p.m., Staff A stated the agency had no documentation of emergency preparedness disaster table top exercises, drills or participation in community based drills for calendar years 2019.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/29/21 through 03/31/21. 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 clinical issues and Staff B was identified as the contact persons for administrative issues. Findings were discussed during an informal exit conference with Staff A, B, C, D, E and F. Deficiencies were cited as a result of the Medicare re-certification survey. Glossary: HHA Home Health Agency MSW Medical Social Work PT Physical Therapy POC Plan of Care SN Skilled Nurse ST Speech Therapy

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 review and interview, the agency failed to ensure: 1. patient education on potential health outcomes related to refusal of SN visits; and 2. physician notification of the patient's continued refusal of SN visits for two (Pt's #4 and #8) of 17 patients. Findings: Patient #4 A review of a POC dated 12/10/20 to 02/07/21 showed a SN visit frequency of one time a week for one week, two times a week for two weeks and then one time a week for six weeks. A review of visit notes showed missed SN visits on 01/08/21, 01/14/21, 01/21/21 and on 01/28/21. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of SN visits and no documentation to the physician of the patient's continued refusal of SN visits. Patient #8 A review of a POC dated 01/21/21 to 03/21/21 showed a SN visit frequency of one time a week for one week and then three times a week for nine weeks. A review of visit notes showed missed SN visits on 02/01/21, 02/08/21, 02/10/21, 02/15/21, 02/17/21, 02/24/21, 02/26/21, 03/08/21, 03/12/21, 03/19/21 and on 03/25/21. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of SN visits and no documentation to the physician of the patient's continued refusal of SN visits. On 03/31/21 at 11:30 a.m., Staff A stated there was no documentation of: 1. attempts to educate the patient of potential health outcomes related to refusal of SN visits for Pt's #4 and #8: and 2. no physician notification of the Pt's #4 and #8 refusal of SN visits.

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 medication embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for five (Pt's #3, 9, 13, 15 and #16) of seventeen patients. Findings: Patient #3 A review of the plan of care dated 12/30/20 to 02/27/21 documented a principal diagnosis of Stage 4 pressure ulcer of the sacrum and ordered home health nursing to perform wound site care using Betadine (a medicated wound care solution) and calcium alginate (a medication embedded dressing material). A review of the clinical record showed no documentation the Betadine or calcium alginate were added to the medication profile or reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. Patient #9 A review of the plan of care dated 02/24/21 to 04/24/21 documented a principal diagnosis of paraplegia with pressure ulcers and ordered home health nursing to perform wound site care using silver nitrate (a medicated wound care supply material) and Iodosorb (a medicated wound care solution). A review of the clinical record showed no documentation the silver nitrate or Iodosorb were added to the medication profile or reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. Patient #13 A review of the plan of care dated 11/25/20 to 01/23/21 documented a principal diagnosis of wound to left great toe and ordered home health nursing to perform wound site care using Iodoform (a medication embedded dressing material) and Xeroform (a medication embedded dressing material with 3% Bismouth Tribromophenate). A review of the clinical record showed no documentation the Iodoform or Xeroform were added to the medication profile or reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. Patient #15 A review of the plan of care dated 12/20/20 to 02/17/21 documented a principal diagnosis of wound to left finger with cellulitis and pressure ulcer to the coccyx and ordered home health nursing to perform wound site care using Aquacel Ag (a medication embedded dressing material). A review of the clinical record showed no documentation the Aquacel Ag was added to the medication profile or reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. Patient #16 A review of the plan of care dated 01/05/21 to 03/05/21 documented a principal diagnosis of stage 3 pressure ulcer to the right lower extremity and ordered home health nursing to perform wound site care using Silvercell (a medication embedded dressing material). A review of the clinical record showed no documentation the Silvercell was added to the medication profile or reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. On 03/31/21 at 11:45 a.m., Staff A stated the medication embedded wound care supplies ordered on Pt's #3, 9, 13, 15 and #16 should have been added to the medication profiles of each patient and reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge oasis assessment was completed for one (Patient #7) of seventeen patients. Findings: Patient #7 A review of the clinical record showed no discharge oasis assessment after the patient's last SN visit on 02/01/21. Documentation showed no communication notes, no discharge visit completed, no physician notification of patient discharge from the home health agency and no changes in orders. On 03/31/21 at 11:45 a.m., Staff A stated no in-patient transfer or discharge oasis assessment was conducted on Patient #7 after the patient was admitted to in-patient hospital services around a 02/02/21 transfer date. Staff A further stated patient #7 did not return to the HHA for continued services and should have been discharged from the agency.

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 POC's included: 1. pain reporting parameters for eight (Pt's #1, 2, 3, 5, 8, 10, 13 and #15) and; 2. interventions and goals related to the primary diagnosis for one (Patient #14) of 17 patients. Findings: Patient #1 A review of the POC dated 01/20/21 to 03/20/21 showed a primary diagnosis of thrombus and SN orders to assess the patient's expectations of pain and to instruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. Patient #2 A review of the POC dated 01/04/21 to 03/04/21 showed a primary diagnosis of bronchitis and SN orders to assess the patient's expectations of pain and instruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. Patient #3 A review of the POC dated 12/30/20 to 02/27/21 showed a primary diagnosis of sacral stage 4 pressure ulcer and SN orders to assess the patient's expectations of pain and instruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. Patient #5 A review of the POC dated 01/10/21 to 03/10/21 showed a primary diagnosis of neurogenic bladder and SN orders to assess the patient's expectations of pain and to instruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. Patient #8 A review of the POC dated 01/21/21 to 03/21/21 showed a primary diagnosis of open wounds to left lower extremity and SN orders to assess the patient's expectations of pain and toinstruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. Patient #10 A review of the POC dated 02/08/21 to 04/08/21 showed a primary diagnosis of multiple sclerosis and SN orders to assess the patient's expectations of pain and to instruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. Patient #13 A review of the POC dated 11/25/20 to 01/23/21 showed a primary diagnosis of open wound to left great toe and SN orders to assess the patient's expectations of pain and ito nstruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. Patient #14 A review of the POC dated 10/28/20 to 12/26/20 showed a primary diagnosis of urinary tract infection. The POC showed no SN interventions or goals related to urinary tract infection and patient management of the urinary system. Patient #15 A review of the POC dated 12/20/20 to 02/17/21 showed a primary diagnosis of cellulite to left finger and SN orders to assess the patient's expectations of pain and to instruct on pain management regimen. Documentation showed no individualized pain reporting parameters to report to the physician. On 03/31/21 at 11:30 a.m. Staff A stated: 1. the POC's for Pt's #1, 2, 3, 5, 8, 10, 13 and #15 should have included pain parameters to report to the physician as a part of assessment and patient pain management instruction and; 2. the POC for Patient #14 should have included SN assessment and patient instruction related to management of the urinary system and urinary tract infection.

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 physician was notified of missed visits for 10 (Pt's #2, 3, 4, 5, 6, 8, 10, 11, 15, 16 and #17) of 17 patients. Findings: Patient #2 A review of the POC dated 01/04/21 to 03/04/21 showed a Home Health Aide frequency of one time a week for nine weeks and a SN frequency of two times a week for three weeks then one time a week for six weeks. A review of clinical documentation showed home health aide visits were missed on 01/11/21, 01/18/21, 01/25/21 and on 02/01/21; and SN visits were missed on 02/19/21 and 02/26/21. Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #3 A review of the POC dated 12/30/20 to 02/27/21 showed a SN frequency of three times a week for nine weeks. A review of clinical documentation showed SN visits were missed on 12/30/20, 01/01/21, 01/18/21, 01/20/21, 01/22/21, 02/15/21 and on 02/17/21. Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #4 A review of the POC dated 12/10/20 to 02/07/21 showed a SN frequency of one week one, two times a week for two weeks, then one time a week for six weeks and a PT frequency of two times a week for four weeks. A review of clinical documentation showed SN visits were missed on 01/08/21, 01/14/21, 01/21/21 and on 01/28/21; and the week of 01/02/21 through 01/08/21 showed one PT visit was conducted (one PT visit was missed.) Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #5 A review of the POC dated 01/10/21 to 03/10/21 showed a SN frequency of one week for nine weeks. A review of clinical documentation showed SN visits were missed during the weeks of 02/06/21 through 02/12/21 no SN visit was conducted (one SN visit missed) and during the week of 02/13/21 through 02/19/21 no SN visit was conducted (one SN visit missed.) Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #6 A review of the POC dated 02/03/21 to 04/03/21 showed: a SN frequency of one time a week for nine weeks; a ST frequency of two times a week for three weeks; and a MSW frequency of one time a week for one week. A review of clinical documentation showed SN visits were missed on 02/12/21, 03/04/21 and 03/18/21; ST visit was missed on 02/15/21; and a MSW visit was missed on 02/10/21. Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #8 A review of the POC dated 01/21/21 to 03/21/21 showed a SN frequency of three times a week for nine weeks. A review of clinical documentation showed a SN visit was missed on 03/22/21. Documentation showed no patient/caregiver refusal of visit, no attempts to reschedule the missed visit, no physician notification of the missed visit and no change in orders. Patient #10 A review of the POC dated 02/08/21 to 04/08/21 showed a Home Health Aide frequency of two times a week for nine weeks and MSW frequency of one time a week for one week. A review of clinical documentation showed Home Health Aide visits were missed on 02/16/21 and 02/18/21and a MSW visit was missed on 02/10/21. Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #11 A review of the POC dated 02/27/21 to 04/27/21 showed a Home Health Aide frequency of two time a week for nine weeks and a SN frequency of three times a week for one week, two times a week for seven weeks, then one time a week for one week. A review of clinical documentation showed home health aide visits were missed on 03/19/21and SN visits were missed during the week 03/06/12 through 03/12/21 (one visit conducted, one visit missed) and on 03/17/21, 03/18/21 and on 03/23/21. Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #15 A review of the POC dated 12/20/20 to 02/17/21 showed a Home Health Aide frequency of two time a week for nine weeks and a SN frequency of three times a week for nine weeks. A review of clinical documentation showed home health aide visits were missed on 12/22/21 and 01/05/21 and a SN visit was missed on 12/30/20. Documentation showed no patient/caregiver refusal of visits, no attempts to reschedule the missed visits, no physician notification of the missed visits and no change in orders. Patient #16 A review of the POC dated 01/05/21 to 03/05/21 showed a SN frequency of one times a week for nine weeks. A review of clinical documentation showed SN visits were missed on 02/19/21 and on 02/22/21. Documentation showed no patient/caregiver refusal of visit, no attempts to reschedule the missed visit, no physician notification of the missed visit and no change in orders. Patient #17 A review of the POC dated 10/10/20 to 12/08/20 showed a SN frequency of three times a day for one weeks. A review of clinical documentation showed SN visits were missed two times on 10/12/20, three times on 10/13/20 and three times on 10/14/20. Documentation showed no patient/caregiver refusal of visit, no attempts to reschedule the missed visit, no physician notification of the missed visit and no change in orders. On 03/31/21 at 12:15 p.m. Staff A stated SN, CHHA, PT, ST and MSW visits that were missed on Pt's #2, 3, 4, 5, 6, 8, 10, 11, 15, 16 and #17 should have been conducted, attempts to reschedule the visits should have been documented and the physicians should have been notified of every missed visit.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of: 1. an in-patient hospital transfer with discharge from the HHA services for one (Patient #7) of seventeen patients and 2. a request for discharge from agency services for one (Patient #13) of seventeen patients. Findings: Patient #7 A review of the clinical record showed a hospitalization without transfer or discharge from agency services after the patient's last SN visit on 02/01/21. Documentation showed no communication notes, no in-patient transfer with discharge completed, no physician notification of patient discharge from the home health agency and no changes in orders. Patient #13 A review of the clinical record showed a non-oasis discharge from agency services on 01/04/21 after the patient's last SN visit on 12/28/21. Documentation showed a communication note dated 12/30/20 of the patient's request for discharge from HHA services. Documentation showed no physician notification of patient's request for discharge, no physician notification of the patient's discharge from the home health agency and no changes in orders. On 03/31/21 at 12:00 p.m., Staff A stated: 1. Patient #7 was transferred to in-patient hospital services with a discharge from the HHA after the last SN visit date of 02/01/21; 2. the physician should have been notified Patient #7 transferred to in-patient services, did not return to the HHA for services and a discharge from agency services should have been completed and 3. the physician should have been notified of Patient #13 request for discharge from HHA services.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of wound care interventions performed by the SN for two (Pt's #7 and #8) of seventeen patients. Findings: Patient #7 A review of the clinical record showed a POC dated 01/30/21 to 03/30/21 with orders for SN to perform wound care every visit. Documentation showed no wound care interventions performed by the SN on a visit note dated 02/01/21, no physician communication and no changes in orders. Patient #8 A review of the clinical record showed a POC dated 01/21/21 to 03/31/21 with orders for SN to perform wound care every visit. Documentation showed no wound care interventions performed by the SN on a visit notes dated 01/25/21 and 02/21/21, no physician communication and no changes in orders. On 03/31/21 at 12:00 p.m., Staff A stated the SN should have documented wound care that was performed on Pt's #7 and #8 during the SN visits.