Every finding on record at Mashovin Home Health Care, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 04/14/25 to 04/15/25. 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 04/14/25 to 04/15/25. An entrance conference was conducted with Staff A and B. Staff A, B and C were identified as the contact persons for administrative issues and Staff C was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Deficiencies were cited as a result of the re-certification survey. Glossary: QAPI- Quality Assessment and Performance Improvement PIP- Performance Improvement Project

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 5 patients and 15 employees. A review of administrative records showed no data collection activities utilized in the agency's QAPI program for the calendar year of 2023, 2024 and from 01/01/25 to 03/11/25. On 04/15/25 at 1:25 pm., Staff C stated there was no collection of quality indicator data for the QAPI program for 2023, 2024 and from 01/01/25 to 03/11/25.

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 maintain a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all five patients and 15 employees. A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency for calendar years 2023, 2024 and from 01/01/25 to 03/11/25. On 04/15/25 at 1:41 pm, Staff C stated they had no QAPI documentation which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services and operations of the agency for the calendar years of 2023, 2024 and from 01/01/15 to 03/11/25.

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 five patients and 15 employees. A review of QAPI records showed no initiation, review, data analysis, or status of PIPs for the calendar years of 2023, 2024 and from 01/01/25 to 03/11/25. On 04/15/25 at 1:45 pm, Staff C stated the agency had no documented PIP activities for 2023, 2024 and from 01/01/25 to 03/11/25.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice from 06/16/22. 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 06/16/22. An entrance conference was conducted with Staff A, B and C. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff D was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, C and D. Deficiencies were cited as a result of the re-certification survey. GLOSSARY: QAPI Quality Assessment and Performance Improvement

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 15 current patients. A review of administrative records showed no quality indicator data collection utilized in the agency's QAPI Program for calendar years of 2020, 2021 and from January 01, 2022 to June 16, 2022. On 06/16/22 at 2:45 pm, Staff D stated they had no quality indicator data available for 2020, 2021 and from January 01, 2022 to June 16, 2022.

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 documented governing body oversite of the conduction of patient centered QAPI Program activities for all 15 patients and employees. A review of administrative records showed no governing body oversite of ongoing QAPI program activities for calendar years 2020, 2021 or for January 01, 2022 to June 16, 2022. On 06/16/22 at 2:55 pm, Staff A stated they had no documentation which showed governing body oversite of QAPI program activities for calendar years of 2020, 2021 or for January 01, 2022 to June 16, 2022.