Every finding on record at Ok4 Home Health Agency, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 01/31/22 to 02/01/22. 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 01/31/22 to 02/01/22. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. The following condition level deficiency was cited as a result of the re-certification survey: 484.65 Quality Assessment/Performance Improvement GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects QAPI Quality Assessment and Performance Improvement

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of significant weight changes for one (Patient #6) of seven patients. Patient #6 A review of a plan of care dated 05/07/21 to 07/05/21 showed a skilled nurse frequency of one visit per week for one week, two visits per week for one week and one visit per week for six weeks and documented the physician to be notified of weight loss or weight gain of five pounds in one week. A review of the electronic medical record showed the following: A skilled nurse assessment dated 05/07/21 documented a patient weight of 174 pounds. A skilled nurse assessment dated 05/13/21 documented a patient weight of 190 pounds (a 16-pound weight gain in six days). A physician communication note showed the physician was notified of a weight outside of ordered parameters but failed to document notification of the 16-pound weight gain. A skilled nurse assessment dated 05/18/21 documented a patient weight off 184.8 pounds (a 5.2-pound weight loss in five days). A physician communication note showed the physician was notified of a weight outside of ordered parameters but failed to document notification of the 5.2-pound weight loss. A skilled nurse assessment dated 06/05/21 documented a patient weight of 174 pounds. A skilled nurse assessment dated 06/06/21 documented a patient weight of 201 pounds (a 26-pound weight gain in one day). A physician communication note showed the physician was notified of a weight outside of ordered parameters but failed to document notification of the 26-pound weight gain. On 02/01/22 at 11:20 am, Staff B stated the physician notification failed to document the amount of weight gained for Patient #6.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program for all patients and employees. This failed practice had the potential to place 79 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See G642. Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place 79 patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See G644. Based on record review and interview, the agency failed to ensure improvement activities were identified and focused on high risk problem-prone areas for 38 current patients. This failed practice had the potential to place 79 current patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. See G648 Based on record review and interview, the agency failed to ensure conduction of a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. The failed practice had the potential to place 79 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See G656. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 38 patients and all employees. This failed practice had the potential to place the agency, all 79 patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See G658. Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. This failed practice had the potential to place all 79 patients and employees at risk for insufficient governing body oversite of agency services and operations. See G660 for details.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program for all patients and employees. This failed practice had the potential to place 79 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency for 2019, 2020 and 2021. On 02/01/22 at 12:40 pm, Staff A stated there was no documentation of a QAPI program for 2019, 2020 and 2021.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place 79 patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for calendar years of 2019, 2020 and 2021. On 02/01/22 at 12:40 pm, Staff A stated they had no analysis of data collected available that showed improved quality of patient care and program improvement data was not available for 2019, 2020 and 2021.

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure improvement activities were identified and focused on high risk problem-prone areas for 79 current patients. This failed practice had the potential to place 70 current patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. A review of administrative records showed a plan for a QAPI Program with no record of data utilization or improvement efforts for 2019, 2020 and 2021. On 02/01/21 at 12:40 pm, Staff A stated there was no documentation of the QAPI program for 2019, 2020 and 2021.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements was sustained for all patients and employees. The failed practice had the potential to place 79 patients and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency for calendar years 2019, 2020 and 2021. On 02/01/22 at 12:40 pm, Staff A stated they had no QAPI documentation for calendar years 2019, 2020 and 2021.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 70 patients and all employees. This failed practice had the potential to place the agency, all 79 patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. A review of QAPI records showed no initiation, review, data analysis, or status of PIPs for the calendar years of 2019, 2020 and 2021. On 02/01/22 at 12:40 pm, Staff A stated the agency had no documented PIP activities for 2019, 2020 and 2021.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. This failed practice had the potential to place all 79 patients and employees at risk for insufficient governance of agency services and operations. A review of administrative records showed no governing body oversite of ongoing QAPI program activities, no patient record audits and no QAPI meetings to improve the care, services and operations of the agency for calendar years 2019, 2020 or 2021. On 02/01/22 at 12:40 pm, Staff A stated they had no documentation which showed governing body oversite of QAPI program activities for calendar years of 2019, 2020 or 2021.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for all 79 patients and staff. A review of administrative records showed no ongoing infection control surveillance data for calendar year's 2020 and 2021. On 02/01/22 at 12:40 pm, Staff A stated the agency had no comprehensive infection surveillance program in place.