Every finding on record at Maranatha Home Health, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/13/24 to 11/14/24. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of administrative records showed no administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency were in place. On 11/14/24 at 11:00 a.m., Staff A stated the agency did not have an Emergency Preparedness Plan with administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure administrative policies and procedures related to an Emergency Preparedness Plan information sharing were in place for all patients and employees. Findings: A review of administrative records showed no administrative policies and procedures related to an Emergency Preparedness Plan information sharing for the agency. On 11/14/24 at 11:00 a.m., Staff A stated the agency did not have administrative policies and procedures in place related to an Emergency Preparedness Plan information sharing for the agency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff. Findings: Administrative records showed no updated Emergency Preparedness Communication Plan which included current staff contact information for the agency. On 11/14/24 at 11:00 a.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for current staff of the agency.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. An emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all employees and; 2. An after-action report was documented after each drill, exercise or plan activation event for all patients and employees. Findings: A review of administrative records showed no emergency preparedness plan testing and training program was developed, implemented and reviewed/updated at least annually. On 11/14/24 at 11:00 a.m., Staff A stated the agency had no emergency preparedness plan testing and training program for all patients and employees.

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 emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for 05/12/23 to 11/14/24 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for 05/12/23 to 11/14/24 (an activation of the EP plan on 01/05/24 [tornado] was documented but showed no staff participation or after-action summary response). On 11/14/24 at 11:00 a.m., Staff A stated: 1. The agency had no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for 05/12/23 to 11/04/24 and; 2. An activation of the EP plan on 01/05/24 was documented but showed no staff participation or after-action summary response.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 11/13/24 to 11/14/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as additional contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the survey. Glossary: CMS Center for Medicare Services DDS developmental disability services POC plan of care PIP performance improvement project QAPI quality assessment and performance improvement ROC resumption of care SN skilled nurse

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure patient consent for the provision of agency care and services were obtained for two (Patients #8 and #9) of 10 patients reviewed. Findings: On 11/13/24 from 11:30 a.m. to 4:30 p.m., a review of clinical patient records reviews in the electronic medical records were completed for patients #1 to #10. Documentation showed no electronic receipt of informed consent for the provision of agency care and services. On 11/14/24 from 12:00 p.m. to 1:00 p.m., Informed consent records were requested for patients #1 to #10. Documentation showed no paper or electronic receipt of for the provision of agency care and services for patients #8 and #9. Staff A stated documentation showed no paper or electronic receipt of for the provision of agency care and services for patients #8 and #9.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure start of care within 48 hours of referral for five (Patients #1, 3, 6, 7 and #8) of 10 patients. Findings: Patient #1 A review of the clinical record showed no date of referral and a SOC date of 01/11/21. Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 11/14/24 at 12:00 p.m., Staff A stated documentation showed no date of referral and if a delay in the SOC was greater than 48 hours; and showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. Patient #3 A review of the clinical record showed no date of referral and a SOC date of 09/08/24. Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 11/14/24 at 12:27 p.m., Staff A stated documentation showed no date of referral and if a delay in the SOC was greater than 48 hours; and showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. Patient #6 A review of the clinical record showed no date of referral and a SOC date of 06/13/24. Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 11/14/24 at 12:54 p.m., Staff A stated documentation showed no date of referral and if a delay in the SOC was greater than 48 hours; and showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. Patient #7 A review of the clinical record showed no date of referral and a SOC date of 10/30/24. Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 11/14/24 at 1:00 p.m., Staff A stated documentation showed no date of referral and if a delay in the SOC was greater than 48 hours; and showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. Patient #8 A review of the clinical record showed no date of referral and a SOC date of 12/27/23. Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 11/14/24 at 1:05 p.m., Staff A stated documentation showed no date of referral and if a delay in the SOC was greater than 48 hours; and showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC included: 1. Primary diagnosis related to the provision of care for home health services for three (Patients #3, 4 and #9) of 10 patients; 2. SN interventions related to medication administration for one (Patient #9) of 10 patients; 3. SN interventions and goals related to blood sugar monitoring for one (Patient #9) of 10 patients. Findings: Patient #3 A review of the POC dated 09/16/24 to 11/14/24 showed orders for SN frequency and duration of three times a day for 60 days. Documentation on the CMS 485 (POC) showed no primary diagnosis for home health services. Documentation showed no physician notifications, and no changes in orders. On 11/14/24 at 12:27 p.m., Staff A stated the CMS 485 (POC) for patient #3 did not show a primary diagnosis for home health services. Patient #4 A review of the POC dated 09/24/24 to 11/22/24 showed orders for SN frequency and duration of three times a day for 60 days. Documentation on the CMS 485 (POC) showed no primary diagnosis for home health services. Documentation showed no physician notifications, and no changes in orders. On 11/14/24 at 12:46 p.m., Staff A stated the CMS 485 (POC) for patient #4 did not show a primary diagnosis for home health services. Patient #9 A review of the POC dated 09/27/24 to 11/25/24 showed orders for SN frequency and duration of one time a week for nine weeks. Documentation on the CMS 485 (POC) showed no orders for SN to administer injectable medication one time a week (Mounjaro 7.5 milligram subcutaneous injection weekly per the medication profile), no orders for SN to monitor and perform FSBS each visit and directed no reporting parameter for blood glucose level; and showed no goal for management of Diabetes Mellitus Type II diagnosis. Documentation showed no physician notifications, and no changes in orders. On 11/14/24 at 1:10 p.m., Staff A stated the CMS 485 (POC) for patient #9 did not show orders for SN to administer injectable medication one time a week (Mounjaro 7.5 milligram subcutaneous injection weekly per the medication profile), no orders for SN to monitor and perform FSBS each visit and directed no reporting parameter for blood glucose level; and showed no goal for management of Diabetes Mellitus Type II diagnosis.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were documented for SN services during and after an in-patient admission for one (Patient #3) of 10 patients. Findings: Patient #3 A review of the POC dated 09/16/24 to 11/14/24 showed orders for SN frequency and duration of three times a day for 60 days. Documentation showed the patient had an in-patient stay from 9/26/24 to 10/04/24. Documentation showed no hospital hold orders for the in-patient stay, no resumption of care (ROC) orders and no post hospital ROC orders for continuing home health services. Documentation showed no physician notifications, and no changes in orders. On 11/14/24 at 12:27 p.m., Staff A stated the clinical record for patient #3: 1. Did not include hospital hold orders for the in-patient stay, no resumption of care (ROC) orders and no post hospital ROC orders for continuing home health services and; 2. We (the Agency) assumed we would just continue the insulin injections three times a day and didn’t need additional orders since the hospital discharge papers, sent from the DDS nurse, didn’t show any changes in the medication list.

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 physician orders for SN visits and SN interventions for medication administration and blood sugar monitoring were obtained for two (Patients #3 and #9) of 10 patients. Findings: Patient #3 A review of the POC dated 09/16/24 to 11/14/24 showed an in-patient stay from 9/27/24 to 10/04/24. Documentation showed no orders for SN visits with interventions to resume a SN frequency and duration of three times a day for 60 days to monitor blood sugar levels, report readings out of reporting parameters, and administer medications (Humalog SS and Humalog 75/25; insulins for the management of blood sugar levels). Documentation showed on 10/05/24 SN visit x2 (no visits ordered, 2 visit conducted; FSBS obtained, insulin medications administered), 10/06/24 to 10/17/24 SN visits x3 each day (no visits ordered, 3 visit conducted; FSBS obtained, insulin medications administered), on 10/18/24 SN visit x2 (no visits ordered, 2 visits conducted; FSBS obtained, insulin medications administered), 10/19/24 to 11/07/24 SN visits x3 each day (no visits ordered, 3 visit conducted; FSBS obtained, insulin medications administered), 11/08/24 SN visit x2 (no visits ordered, 2 visits conducted; FSBS obtained, insulin medications administered), 11/09/24 to 11/10/24 SN visits x3 each day (no visits ordered, 3 visit conducted; FSBS obtained, insulin medications administered), and on 11/11/24 x2 (no visits ordered, 2 visits conducted; FSBS obtained, insulin medications administered). Documentation showed no physician notifications, and no changes in orders. On 11/14/24 at 12:27 p.m., Staff A stated the clinical record for patient #3: 1. Did not include resumption of care (ROC) orders for continuing home health services and; 2. We (the Agency) assumed we would just continue the insulin injections three times a day and didn’t need additional orders since the hospital discharge papers, sent from the DDS nurse, didn’t show any changes in the medication list. Patient #9 A review of the POC dated 09/27/24 to 11/25/24 showed orders for SN frequency and duration of one time a week for nine weeks. Documentation on the CMS 485 (POC) showed no orders for SN to administer injectable medication one time a week (Mounjaro 7.5 milligram subcutaneous injection weekly per the medication profile), no orders for SN to monitor and perform FSBS each visit and directed no reporting parameter for blood glucose level. Documentation showed on 10/02/24 SN visit x1 (no visit ordered; FSBS obtained, medication administered), 10/09/24 SN visit x1 (no visit ordered; FSBS obtained, medication administered), 10/16/24 SN visit x1 (no visit ordered; FSBS obtained, medication administered), 10/23/24 SN visit x1 (no visit ordered; FSBS obtained, medication administered), 10/30/24 SN visit x1 (no visit ordered; FSBS obtained, medication administered), and on 11/06/24 SN visit x1 (no visit ordered; FSBS obtained, medication administered). Documentation showed no physician notifications, and no changes in orders. On 11/14/24 at 1:10 p.m., Staff A stated the clinical record for patient #9: 1. Did not show orders for SN to administer injectable medication one time a week (Mounjaro 7.5 milligram subcutaneous injection weekly per the medication profile) and; 2. Showed no orders for SN to monitor and perform FSBS each visit and directed no reporting parameter for blood glucose level.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for four (Patients #1, 2, 3 and #4) of 10 patients. Findings: Patient #1 A review of plans of care dated 12/23/23 to 02/22/24, 02/23/24 to 04/22/24, 04/23/24 to 06/23/24 and 06/24/24 to 08/22/24 and 10/22/24 to 12/20/24 documented diagnoses of Intellectual disabilities and showed orders for SN visit frequency of one time a day for 60 days for SN to perform assessment and monitoring of health conditions and report blood pressure less than 90/45 or greater than 180/90 every visit. Documentation showed blood pressure readings on: 01/11/24 of 164/111, 01/16/24 of 157/99, 01/17/24 of 171/118, 01/24/24 of 189/150 (right arm) & 72/41 (left arm), 02/24/24 of 148/104, 05/03/24 of 152/102, 05/13/24 of 70/50, 06/15/24 of 85/50, 06/18/24 of 71/50 and on 08/02/24 of 125/111 documentation showed auto faxed communication log notes but showed no follow up communication or coordination of care of communications to the physician of blood pressure readings outside of the reporting parameters and showed no changes in orders. On 11/14/24 at 12:00 p.m., Staff A stated the agency did not notify the physician of changes in the patient’s condition and showed no follow up communication to the physician of blood pressure readings outside of the reporting parameters. Patient #2 A review of plans of care dated 07/03/24 to 09/02/24 and 09/03/24 to 11/01/24 documented diagnoses of intellectual disabilities and showed orders for SN visit frequency of three times a day for 60 days for SN to perform assessment and monitoring of health conditions and report blood sugar levels of less than 60 and greater than 300 every visit. Documentation showed blood sugar readings reported on 09/10/24 for blood sugar levels obtained on 08/19/24 to 09/09/24 SN visits. Documentation showed no physician notification of blood sugar readings out parameters during SN visits on 08/21/24 of 334, 08/23/24 of 311, 08/28/24 of 315, 08/29/24 of 303, 09/03/24 of 326; a patient communication log dated 09/23/24 showed an auto fax communication that stated FSBS of 436 and 463, “patient did not receive Lantus [insulin] for two nights as caregiver left patient’s Lantus in adult day care center on Friday [date not specified]”; and reported on 10/23/24 for blood sugar levels obtained on 10/01/24 to 10/22/24 SN visits documentation showed no physician notification of blood sugar readings out parameters during SN visits on 10/20/24 of 310. Documentation showed no follow up communication or coordination of care communications to the physician of blood sugar readings outside of the reporting parameters at the time of the SN visits and showed no changes in orders. On 11/14/24 at 12:20 p.m., Staff A stated the agency did not notify the physician of changes in the patient’s condition and showed no follow up communication to the physician of blood sugar readings outside of the reporting parameters at the time of the SN visits. Patient #3 A review of plans of care dated 09/16/24 to 11/14/24 documented no primary diagnoses for home health services and showed orders for SN visit frequency of three times a day for 60 days for SN to perform assessment and monitoring of health conditions and report blood sugar levels of less than 60 and greater than 300 every visit. Documentation showed blood sugar readings on 10/06/24 of 343, 10/07/24 of 310, 10/14/24 of 333, 10/18/24 of 394, 10/20/24 of 324 and on 11/10/24 of 318. Documentation showed no follow up communication or coordination of care communications to the physician of blood sugar readings outside of the reporting parameters at the time of the SN visits and showed no changes in orders. On 11/14/24 at 12:27 p.m., Staff A stated the agency did not notify the physician of changes in the patient’s condition and showed no follow up communication to the physician of blood sugar readings outside of the reporting parameters at the time of the SN visits. Patient #4 A review of plans of care dated 09/24/24 to 11/22/24 documented no primary diagnoses for home health services and showed orders for SN visit frequency of three times a day for 60 days for SN to perform assessment and monitoring of health conditions and report blood sugar levels of less than 60 and greater than 300 every visit. Documentation showed blood sugar readings on 09/21/24 of 313, 10/06/24 of 313, 10/14/24 of 309, 10/13/24 of 335, and on 10/26/24 of 312. Documentation showed no follow up communication or coordination of care communications to the physician of blood sugar readings outside of the reporting parameters at the time of the SN visits and showed no changes in orders. On 11/14/24 at 12:46 p.m., Staff A stated the agency did not notify the physician of changes in the patient’s condition and showed no follow up communication to the physician of blood sugar readings outside of the reporting parameters at the time of the SN visits.

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 employees. Findings: A review of administrative QAPI records for calendar year 2023 and 01/01/24 to 11/14/24 showed no data collection sources or activities utilized in the analysis of data in the agency's QAPI Program. On 11/14/24 at 11:00 a.m., Staff A stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. QAPI program documentation showed no program improvement data or analysis of collected data that showed improved quality of patient care for calendar year 2023 and 01/01/24 to 11/14/24.

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. 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 that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations for all patients and employees. Findings: A review of administrative QAPI records for calendar years 2023, and 01/01/24 to 11/14/24 showed no documentation of patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services, and operations. On 11/14/24 at 11:00 a.m., Staff A stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services, and operations for calendar year 2023, and 01/01/24 to 11/14/24.

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 selection, review and reporting of ongoing PIP data through the QAPI program for 01/01/24 to 11/14/24 for all patients and employees. Findings: A review of administrative QAPI program documents showed no PIP data selection or reporting for 01/01/24 to 11/14/24. On 11/14/24 at 11:00 a.m., Staff A stated QAPI program documentation showed no PIP selection or reporting of PIP data for 01/01/24 to 11/14/24.

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 a patient centered QAPI program for calendar year 2023, and 01/01/24 to 11/14/24 for all patients and employees. Findings: A review of administrative records showed no governing body oversite of the conduction of a patient centered QAPI program for calendar year 2023, and 01/01/24 to 11/14/24 for the agency. On 11/14/24 at 11:00 a.m., Staff A stated administrative QAPI records showed no documentation of governing body oversite of the conduction of a patient centered QAPI program for calendar year 2023, and 01/01/24 to 11/14/24.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Infection Control Program surveillance data was included in QAPI program activities for all patients and employees. Findings: A review of QAPI administrative records showed no documentation of infection control surveillance data through the QAPI program for calendar year 2023, and 01/01/24 to 11/14/24. On 11/14/24 at 11:00 a.m., Staff A stated infection surveillance activities were not reported through the agency's QAPI program for calendar year 2023, and 01/01/24 to 11/14/24.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN services (visits) were provided as ordered on the POC for one (Patient #4) of 10 patients. Findings: Patient #4 A review of an updated POC dated 09/24/24 to 11/22/24 showed orders for SN visit frequency of three times a day for 60 days for SN to perform assessment and monitoring of health conditions and report blood sugar levels of less than 60 and greater than 300 every visit. On 09/27/24 three SN visits were ordered; 1 SN visit was missed. Documentation showed no patient refusal of visit, no physician notification, and no changes in orders. On 11/14/24 at 12:46 p.m., Staff A stated SN should have followed the POC and conducted the three SN visits as ordered.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: Administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar year 2023, and for 01/01/24 to 11/14/24. On 11/14/24 at 11:00 a.m., Staff A stated documentation showed no multi-disciplined skilled professional staff participation in ongoing QAPI program activities in calendar year 2023, and for 01/01/24 to 11/14/24 for the agency.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the agency’s program evaluation for calendar year 2023, and 01/01/24 to 11/14/24 for all patients and employees. Findings: Administrative records showed no governing body over-site and responsibility for the agency’s program evaluation for calendar year 2023, and 01/01/24 to 11/14/24. On 11/14/24 at 11:00 a.m., Staff A stated documentation showed no oversight of the agency’s program evaluation for calendar year 2023, and 01/01/24 to 11/14/24.

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 clinical visit note documentation was completed for five (Patients #1, 2, 5, 6 and #9) of 10 patients. Findings: Patient #1 A review of the POC dated 10/22/24 to 12/20/24 showed orders for SN visit frequency of one time a day for 60 days for SN to assess and monitor health conditions and administer Degludec (diabetic medication) 10 units subcutaneous injection each visit. Documentation on SN visit notes dated 11/04/24, 11/05/24, 11/09/24, 11/10/24, 11/11/24 and on 11/12/24 identified no medication name and dose that was administered by the SN in the clinical record visit notes (the electronic clinical record system tagged each note with message, ‘see MAR [medication list]’. Documentation showed no coordination of care that identified medication name and dose that was administered by the SN during the SN visits. Patient #2 A review of the POC dated 11/02/24 to 12/31/24 showed orders for SN visit frequency of three times a day for 60 days for SN to assess and monitor health conditions and administer Lantus (diabetic medication) 34 units subcutaneous injection each visit, and Humalog insulin Sliding Scale dose based on FSBS readings subcutaneous injection each visit. Documentation on SN visit notes dated 11/02/24 x3 SN visits, 11/03/24 x3 SN visits, 11/04/24 x3 SN visits, 11/05/24 x3 SN visits, 11/06/24 x3 SN visits, 11/07/24 x3 SN visits, 11/08/24 x3 SN visits, 11/09/24 x3 SN visits, 11/10/24 x3 SN visits, and on 11/11/24 x3 SN visits: identified no medication name and dose that was administered by the SN in the clinical record visit notes (the electronic clinical record system tagged each note with message, ‘see MAR [medication list]’. Documentation showed no coordination of care that identified medication name and dose that was administered by the SN during the SN visits. Patient #5 A review of the POC dated 09/16/24 to 11/14/24 showed orders for SN visit frequency of two times a day for 60 days for SN to assess and monitor health conditions and administer Lantus (diabetic medication) 35 units subcutaneous injection each visit, and Victoza 1.8 milligrams subcutaneous injection each AM visit. Documentation on SN visit notes dated 10/16/24 x2 SN visits, 10/17/24 x2 SN visits, 10/18/24 x2 SN visits, 10/19/24 x2 SN visits, 10/20/24 x2 SN visits, 10/21/24 x2 SN visits, 10/22/24 x2 SN visits, 10/23/24 x2 SN visits, 10/24/24 x2 SN visits, 10/25/24 x2 SN visits, 10/26/24 x2 SN visits, 10/27/24 x2 SN visits, 10/28/24 x2 SN visits, 10/29/24 x2 SN visits, 10/30/24 x2 SN visits, 10/31/24 x2 SN visits, 11/01/24 x2 SN visits, 11/02/24 x2 SN visits, 11/03/24 x2 SN visits, 11/04/24 x2 SN visits, 11/05/24 x2 SN visits, 11/06/24 x2 SN visits, 11/07/24 x2 SN visits, 11/08/24 x2 SN visits, 11/09/24 x2 SN visits, 11/10/24 x2 SN visits, 11/11/24 x2 SN visits and on 11/12/24 x2 SN visits: identified no medication name and dose that was administered by the SN in the clinical record visit notes (the electronic clinical record system tagged each note with message, ‘see MAR [medication list]’. Documentation showed no coordination of care that identified medication name and dose that was administered by the SN during the SN visits. Patient #6 A review of the POC dated 10/11/24 to 12/09/24 showed orders for SN visit frequency of one time a week for nine weeks for SN to assess and monitor health conditions and administer Novolog (insulin) at time of visit: 15 units AM, 25 units Lunch, 35 units Dinner and 10 units with snack subcutaneous injection each visit. Documentation on SN visit notes dated 10/26/24, 11/02/24 and on 11/09/24 identified no medication name and dose that was administered by the SN in the clinical record visit notes (the electronic clinical record system tagged each note with message, ‘see MAR [medication list]’. Documentation showed no coordination of care that identified medication name and dose that was administered by the SN during the SN visits. Patient #9 A review of the POC dated 09/27/24 to 11/25/24 showed orders for SN visit frequency of one time a week for nine weeks for SN to assess and monitor health conditions and administer Mounjaro (diabetic medication) 7.5 milligrams subcutaneous injection on Wednesdays each visit. Documentation on SN visit notes dated 10/02/24, 10/09/24, 10/16/24, 10/23/24, 10/30/24 and on 11/06/24 identified no medication name and dose that was administered by the SN in the clinical record visit notes (the electronic clinical record system tagged each note with message, ‘see MAR [medication list]’. Documentation showed no coordination of care that identified medication name and dose that was administered by the SN during the SN visits. On 11/14/24 at 12:00 p.m. to 1:10 p.m., Staff A stated for patients #1, 2, 5, 6 and #9: 1. The electronic clinical visit notes tag each SN visit note with a tagged message of: ‘see MAR [medication list]’ and; 2. The SN doesn’t have to document the name or dose of the medication administered to the patients during the visit.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided to the receiving service provider for two (Patients #3 and #8) of 10 patients. Findings: Patient #3 A review of the clinical record documented transfer from the agency on 09/26/24 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the receiving inpatient hospital service provider. Patient #8 A review of the clinical record documented discharge from the agency on 04/25/24. Documentation showed no discharge summary was provided to the physician. On 11/14/24 at 12:27 p.m. to 1:05 p.m., Staff A stated documentation showed no transfer/discharge summary was sent to the receiving service providers for patients #3 and #8.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 11/18/21. 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 11/18/21. 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 clinical issues. Findings were discussed during an informal exit conference with Staff A. Deficiencies were cited as a result of the re-certification survey.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure update of the comprehensive nurse assessments to reflect the current status of wounds for one (Patient #6) of seven patients. A review of the plan of care showed a certification period of 06/03/21 to 08/01/21 and documented the presence of a non pressure ulcer of left ankle and non pressure ulcer of lower leg. Skilled nurse assessments dated 06/08/21, 06/11/21, 06/18/21 and 06/21/21 documented the presence of five additional "closed" wounds, each documenting the presence of wound drainage. On 11/18/21 at 2:55 pm., Staff A stated the skilled nurse assessments showing the five additional wounds were incorrect due to a electronic charting error.

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 plan of care development included diagnosis appropriate interventions for two (Patients #1 and 7) of 7 patients. Patient #1 A review of the plan of care showed a certification period of 08/07/21 to 10/05/21 and documented a primary diagnosis of hypertensive kidney disease . The plan of care failed to document the monitoring of weight, obtaining weights or teaching to the patient the importance of significant weight gain or weight loss related to disease process. Patient #7 A review of the plan of care showed a certification period of 06/28/21 to 08/26/21 and documented a primary diagnosis of cancer of the dome of bladder. The plan of care failed to document the monitoring of pain, monitoring of difficulty with urination and teaching of difficulty with urination. On 11/18/21 at 2:14 pm., Staff A stated the plan of care did not provided patient specific interventions related to the primary diagnosis for Patient #1 and 7.