Every finding on record at Live Well Home Care, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 04/09/25 to 04/10/25. 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 on 04/09/25 to 04/10/25. An entrance conference was conducted with Staff A and B. Staff A and B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the re-certification survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physician order was obtained for discharge of one (Patient #7) of seven patients. A review of the plan of care dated 01/24/25 to 03/24/25 showed a diagnosis of primary central nervous system lymphoma. A review of the clinical record showed a discharge summary was completed on 02/28/25 due to being admitted to hospice. The clinical record showed no physician order for discharge from the agency. On 04/10/25 at 1:30 pm., Staff A stated there was no order to discharge Patient #7 from the agency.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy services were provided as ordered for one (Patient #7) of seven patients. Patient #7 A review of the plan of care dated 01/24/25 to 03/24/25 showed a diagnosis of primary central nervous system lymphoma and a physical therapy frequency of two visits per week for four weeks. A review of the clinical record showed the following: A physical therapy assessment dated 02/04/25 and a physical therapy missed visit (due to the patient went to the emergency room) note dated 02/06/25 for the week of 02/02/25 to 02/06/25 (one of two completed visits) with no patient refusal, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. A physical therapy missed visit (due to inclimate weather) and a physical therapy assessment dated 02/22/25 for the week of 02/16/25 to 02/22/25 (one of two completed visits with no patient refusal of services, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. On 04/10/25 at 1:45 pm., Staff A stated the ordered frequency was no met for Patient #7.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice from 06/08/22 to 06/09/22. 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 06/08/22 to 06/09/22. 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 and B The following condition level deficiency was cited as a result of the re-certification survey: 484.65 Quality Assessment/Performance Improvement GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects QAPI Quality Assessment and Performance Improvement

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the hospice failed to ensure orders were obtained for skilled nursing services for one (Patient #6) of seven patients. A review of the plan of care dated 12/14/21 to 02/11/22 showed no orders for skilled nurse frequencies. A physician's order dated 01/10/22 ordered a skilled nurse assess for the week of 01/10/22. A review of the clinical record showed the following: A skilled nurse assessment dated 01/17/22. A skilled nurse assessment dated 01/20/22. A skilled nurse assessment dated 01/24/22. A skilled nurse assessment dated 01/31/22. A skilled nurse assessment dated 02/07/22. On 06/09/22 at 11:00 am, Staff B stated there were no documented orders for the skilled nurse visits made after the week of 01/10/22.

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 documentation of a patient centered QAPI Program for all patients and employees. This failed practice had the potential to place 68 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 quality indicator data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place 68 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 68 current patients. This failed practice had the potential to place 38 current patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. See G648 Based on record review and interview, the agency failed to ensure conduction of a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. The failed practice had the potential to place 68 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See G656. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 68 patients and all employees. This failed practice had the potential to place the agency, all patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See G658

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 documentation of a patient centered QAPI Program for all 68 patients and employees. This failed practice had the potential to place 68 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no documented ongoing patient centered QAPI program and no documented quality indicator data collected, monitored or evaluated by the agency for 2020 and 2021. On 06/09/21 at 11:41 am, Staff B stated there was no documentation of a QAPI program for 2020 and 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 quality indicator data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place 68 patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. A review of administrative records showed no quality indicator data collection utilized in the agency's QAPI Program for calendar years of 2020 and 2021. On 06/09/21 at 11:41 am, Staff B stated they had no analysis of quality indicator data collected which showed improved quality of patient care and program improvement data was not available for 2020 and 2021.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. The failed practice had the potential to place 68 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency for calendar years 2020 and 2021. On 06/09/22 at 11:41 am, Staff B stated they had no QAPI documentation for calendar years 2020 and 2021.

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 review of a PIP through their QAPI Program for 68 patients and all employees. This failed practice had the potential to place the agency, all 68 patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. A review of QAPI records showed no review, data analysis, or status of PIPs for the calendar years of 2020 and 2021. On 06/09/22 at 11:41 am, Staff B stated the agency had no documented review, data analysis or status of PIP activities for 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 documentation of an Infection Control Program which included interventions to reduce future infections and promote learning and preventative measures throughout the agency for all 68 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 2020 and 2021. On 06/09/22 at 11:41 am, Staff B stated the agency had no documentation of a comprehensive infection program in place to reduce future infections and provide preventative measures for 2020 and 2021.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview the hospice failed to ensure proof of the COVID-19 vaccination or provide acceptable waiver of the COVID-19 vaccination for five (Staff D, E, F, G and H) of five employees. Staff D A review of the employee file failed to contain proof of COVID-19 vaccination or an acceptable waiver of COVID-19 vaccination. Staff E A review of the employee file failed to contain proof of COVID-19 vaccination or an acceptable waiver of COVID-19 vaccination. Staff F A review of the employee file failed to contain proof of COVID-19 vaccination or an acceptable waiver of COVID-19 vaccination. Staff G A review of the employee file failed to contain proof of COVID-19 vaccination or an acceptable waiver of COVID-19 vaccination. Staff H A review of the employee file failed to contain proof of COVID-19 vaccination or an acceptable waiver of COVID-19 vaccination. On 06/09/22 at 12:35 pm, Staff A stated they were not aware the COVID-19 vaccination or an acceptable waiver of the COVID-19 vaccination were required.