Every finding on record at Mcalester Regional Health Center Authority

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/01/24 to 10/02/24. Standard deficiencies were cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) that identified a date the assessment was developed and implemented and/or was review for all patients and employees. Findings: A review of administrative records showed an undated community-based risk assessment. Documentation showed no date of assessment or review for the agency, its patient population, or its employees. On 10/02/24 at 1:30 p.m., Staff A stated the date of the assessment was unknown and documentation showed no date of last review of the AHRA.

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 for the agency included current employee contact information for all patients and employees. Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan for the agency included current employee contact information for all patients and employees. Findings: A review of administrative records showed documentation the Emergency Preparedness Communication Plan did not include updated current employee contact information for the agency. On 10/02/24 at 1:30 p.m., Staff A stated the Emergency Preparedness Communication Plan for the agency did not include updated current employee contact information.

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 declaration, table-top exercises, drills, community drills or plan activation events were conducted for 05/12/23 to 12/31/23 and documentation showed no after-action summary reporting for events on 02/19/24 and 08/08/24 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/12/23 to 12/31/23 and documentation showed no after-action summary reporting for events on 02/19/24 and 08/08/24. On 10/02/24 at 1:30 p.m., Staff B stated the agency had no emergency preparedness disaster declarations, table-top exercises, drills, community drills or plan activation events for 05/12/23 to 12/31/23 and documentation showed no after-action summary reporting for events on 02/19/24 and 08/08/24.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/01/24 to 10/02/24. 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 person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the survey. Glossary: EP Emergency Preparedness HHA Home Health Agency PIP performance improvement plan POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a transfer/discharge summary was completed for one (Patient #6) of eight patients. Findings: Patient #6 A review of the clinical record documented discharge to hospice provider services on 09/30/24. Documentation showed no discharge summary was completed/provided to the hospice service provider. On 10/02/24 at 2:20 p.m., Staff A stated the discharge summary was not completed and provided to the receiving hospice service providers for patients #6.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC included: 1. SN catheter treatment/interventions or last changed/treatment due date related to suprapubic urinary catheter management for one (Patient #3) of eight patients; 2. SN intervention for venipuncture/lab draw with last competed or intervention due date related to venipuncture/lab draw for three (Patients #3, 6 and #8) of eight patients; and 3. An individualized patient POC included pain reporting parameters for one (Patient #7) of eight patients. Findings: Patient #3 A review of the POC dated 08/14/24 to 10/12/24 showed orders for SN to perform monthly foley catheter changes using a 16/10 French catheter and interventions to perform venipuncture lab draw for HgB A1C (a laboratory test for blood glucose management) every 4 months. POC documentation showed no urinary catheter treatment intervention last changed or monthly change due date and no last conducted or due date for venipuncture lab draw. Documentation showed no physician notification and no changes in orders. On 10/02/24 at 2:05 p.m., Staff A stated the POC for patient #3 should have included catheter treatment interventions last changed or monthly change due date related to urinary foley catheter management and last conducted or due date for venipuncture lab draw for HgB A1C. Patient #6 A review of the POC dated 09/04/24 to 11/02/24 showed orders for SN to perform interventions to perform venipuncture lab draw for Hgb & HCT, Chem 7, Albumin, Magnesium, and Phosphorus levels (laboratory tests for medical management of health conditions) every 2 weeks. POC documentation showed no last conducted or due date for venipuncture lab draw. Documentation showed no physician notification and no changes in orders. On 10/02/24 at 2:20 p.m., Staff A stated the POC for patient #6 should have included last conducted or due date for venipuncture lab draw for Hgb & HCT, Chem 7, Albumin, Magnesium, and Phosphorus levels. Patient #7 A review of the POC dated 07/03/24 to 08/31/24 showed orders for SN and PT to conduct assessment and monitoring of patient pain level every visit. Documentation showed no physician pain reporting parameters on the POC and showed a pain goal of less than 6 on a scale of 10. Documentation showed PT visits were conducted on 07/16/24 with a patient reported a pain level of 2 and on 07/19/24 with a patient reported a pain level of 1. Documentation showed no physician notifications and no change in orders. On 10/02/24 at 2:25 p.m., Staff A stated the POC for patient #7 should have included physician pain reporting parameters. Patient #8 A review of the POC dated 08/14/24 to 10/12/24 showed orders for SN to perform interventions to perform venipuncture lab draw for HgB A1C (a laboratory test for blood glucose management) every 4 months. POC documentation showed no last conducted or due date for venipuncture lab draw. Documentation showed no physician notification and no changes in orders. On 10/02/24 at 2:30 p.m., Staff A stated the POC for patient #8 should have included last conducted or due date for venipuncture lab draw for HgB A1C.

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 one (Patient #6) of eight patients. Findings: Patient #6 A review of the POC dated 09/04/24 to 11/02/24 showed documentation of discharge to hospice provider services on 09/30/24. SN visit note dated 09/25/24 documented the patient requests discharge to hospice services. Documentation showed no physician communications or coordination of care notes related to patient request to discharge to hospice services and showed no coordination of care with the hospice service provider. On 10/03/24 at 2:20 p.m., Staff A stated the clinical record for patient #6 should have included physician communications and showed no coordination of care with the hospice service provider before the patient’s discharge from agency services.

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 show utilization and analysis of quality indicator data in its QAPI program to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative records showed no utilization and analysis of quality indicator data in its QAPI program for calendar years 2022, 2023 and 01/01/24 through 10/02/24. On 10/03/24 at 1:30 p.m., Staff B stated the agency had no documentation which showed utilization and analysis of quality indicator data in its QAPI program for calendar years 2022, 2023 and 01/01/24 through 10/02/24.

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 initiation and review of a PIP through its QAPI Program in calendar year 2022, and 01/01/24 to 10/02/24 for all patients and employees. Findings: Administrative records of an ongoing patient centered QAPI program showed no PIP through the QAPI Program for the agency for calendar year 2022, and 01/01/24 to 10/02/24. On 10/02/24 at 1:30 p.m., Staff A stated the agency had no QAPI PIP records for calendar year 2022, and 01/01/24 to 10/02/24.

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 years 2022, 2023 and 01/01/24 to 10/02/24. On 10/02/24 at 1:30 p.m., Staff A stated infection surveillance activities were not reported through the agency's QAPI program for calendar years 2022, 2023 and 01/01/24 to 10/02/24.

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 years 2022, 2023 and 01/01/24 to 10/02/24. On 10/02/24 at 1:30 p.m., Staff B stated documentation showed no evidence of multi-disciplined skilled professional staff participation in ongoing QAPI program activities 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: 1. QAPI program activities for calendar years 2022, 2023 and 01/01/24 to 10/02/24 and; 2. Agency program evaluation for calendar years 2022, 2023 and for 01/01/24 to 10/02/24 for all patients and employees. Findings: A review of administrative records (governing body minutes) showed no governing body oversite and responsibility for the agency’s QAPI program activities and agency program evaluation for calendar years 2022, 2023 and for 01/01/24 to 10/02/24. On 10/02/24 at 1:45 a.m., Staff B stated documentation showed no administrative records which showed evidence of ongoing governing body oversite and responsibility for the agency’s QAPI program activities or the agency’s program evaluation for calendar years 2022, 2023 and for 01/01/24 to 10/02/24.

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 transfer summary was provided to the receiving service provider for one (Patient #5) of eight patients. Findings: Patient #5 A review of the clinical record documented transfer to in-patient hospital services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. On 10/02/24 at 2:10 p.m., Staff A stated the transfer summary was not provided to the receiving in-patient service provider for patients #5.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/05/21 to 10/06/21. 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 10/05/21 through 10/06/21. 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 and clinical 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. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: OT Occupational Therapy PIP Performance Improvement Project PTA Physical Therapy Assistant Pts Patients QAPI Quality Assurance Performance Improvement

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 ordered medication for one (Patient #1) of 10 patients. Findings: Patient #1 A review of an interim physician's order dated 08/02/21 showed orders for procardia 90 mg every morning for blood pressure control. A review of the clinical record showed no update to the plan of care medication profile for the medication. On 10/06/21 at 2:00 p.m., Staff B stated the medication should have been included on the medication profile.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure occupational therapy services were available for two (Patient's #4 and #6) of 10 patients. Findings: Patient #4 A review of the POC dated 08/19/21 to 10/17/21 showed an OT frequency of one time a week for four weeks. A physicians order dated 08/25/21 showed OT was discontinued due to no OT service provider available for the agency. Documentation showed during the week of 08/19/21 through 08/21/21 no OT visits were conducted (one missing OT visit) and during the week of 08/22/21 through 08/25/21 no OT visits was conducted (one missing OT visit). Documentation showed no patient/caregiver refusal of visit, physician notification, or changes in orders prior to 08/25/21. Patient #6 A review of the POC dated 08/28/21 to 10/22/21 showed orders for an OT evaluation. A communication note dated 08/30/21 showed the OT evaluation was discontinued due to no OT service provider available for the agency. Documentation showed during the week of 08/28/21 and 08/29/21 through 08/30/21 no OT evaluation was conducted (one missing OT evaluation). Documentation showed no patient/caregiver refusal of visit, physician notification prior to 08/30/21, or changes in orders. On 10/06/21 at 2:00 p.m., Staff B stated the OT staff were not available to provide OT services to Patient's #4 and #6 and that the agency should have had OT service providers available.

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 evidence of a patient centered QAPI Program for 79 patients and all employees for calendar year 2019. Findings: A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency for calendar year 2019. On 10/06/21 at 11:30 a.m., Staff A stated there was no documentation which showed a QAPI program for calendar year 2019.

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 79 patients and all employees. Findings: A review of administrative records showed no data collection activities utilized in an agency QAPI Program for calendar year 2019. On 10/06/21 at 11:30 a.m., Staff A stated: 1. They had no analysis of data collected available that showed improved quality of patient care for calendar year 2019 and; 2. Program improvement data was not available for calendar year 2019.

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 79 patients and all employees. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar year 2019. On 10/06/21 at 11:30 a.m., Staff A stated they had no agency QAPI documentation which showed QAPI program activities for calendar year 2019.

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 required documentation and review of designated PIP's through their QAPI Program for 79 patients and all employees. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs in calendar year 2019. Documentation showed no PIP goals, anticipated review date, or a designated time to follow-up for calendar year 2020. On 10/06/21 at 11:30 a.m., Staff A stated the agency had no documentation which showed: 1. a PIP for calendar year 2019 and; 2. the PIP documentation for calendar year 2020 showed no goals, anticipated review date, status or time of follow up.

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 patient centered QAPI Program activities for 79 patients and all employees. Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities and no regular QAPI meetings to improve the care, services, and operations of the agency for calendar year's 2019 and 2020. Documentation showed no COVID19 focused activities for calendar year 2020. On 10/06/21 at 11:30 a.m., Staff A stated they had no documentation which showed governing body oversite of QAPI program activities for calendar year's 2019 and 2020.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physical therapy discharge assessment was conducted by a Physical Therapist for one (Patient #4) of 10 patients. Findings: Patient #4 A review of the clinical record showed a PT evaluation dated 08/25/21 and orders for PT frequency of one time a week for four weeks. A review of visit notes showed physical therapy assistant visits conducted on 08/31/21, 09/09/21 and on 09/16/21. Documentation showed the discharge assessment and the physical therapy discharge summary was completed by the PTA on 09/16/21. On 10/06/21 at 2:30 p.m., Staff A stated the agency allowed PTA's to conduct physical therapy discharge assessments and complete physical therapy discharge summaries in leu of requiring a PT to do them.

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: 1. agency program evaluation and; 2. an operating budget and allocation of resources activities for calendar year's 2019, 2020 and 01/01/21 to 08/04/21 effecting 79 patients and all staff. Findings: A review of administrative records showed no: 1) governing body oversite of an ongoing agency program and; 2) operating budget and allocation of resource activities for calendar year's 2019, 2020 and 01/01/21 to 08/04/21. On 10/06/21 at 1:00 p.m., Staff A stated there were no governing body minutes that showed documentation of governing body oversight of: 1. the agency program evaluations and; 2. an operating budget and allocation of resources activities for calendar year's 2019, 2020 and 01/01/21 to 08/04/21.

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 review and interview, the agency failed to ensure a completed discharge summary was provided for one (Patient #10) of 10 patients. Findings: Patient #10 A review of the clinical record showed the patient was discharged from the agency on 08/12/21 to hospice care services. Documentation showed no discharge summary provided to the hospice service provider. On 10/06/21 at 2:00 p.m., Staff B stated no discharge summary was sent to the hospice service provider for Patient #10.