Every finding on record at Oklahoma Healthcare Transitions Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/18/26 to 02/19/26. 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) was reviewed and updated every two years for all patients and employees. Findings: A review of emergency preparedness records showed no review and update of a community-based risk assessment dated 12/04/22. On 02/19/26 at 9:20 a.m., Staff C stated the risk assessment was not updated after 12/04/22.

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 current employee contact information for the agency for all patients and employees. Findings: A review of emergency preparedness program records included employee contact information who were no longer employed by the agency. On 02/19/26 at 9:20 a.m., Staff C stated the emergency preparedness communication plan was not updated.

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 in calendar year 2024 for all patients and employees. Findings: A review of emergency preparedness records showed no disaster table-top exercises, drills, community drills or plan activation events for calendar year 2024. On 02/19/26 at 9:20 a.m., Staff C stated the agency had no disaster events or exercises in 2024.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency 02/18/26 to 02/19/26. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff C was identified as the contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff B and C. Standard level deficiencies were cited as a result of the survey. Glossary: eMR electronic medical record HHA Home Health Agency OT Occupational Therapy POC Plan of Care PT Physical Therapy SN skilled nurse

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure informed consents were obtained and accessible for three (Patients #5, 8 and #10) of 10 patients. Findings: Patient #5 A review of a plan of care dated 12/27/25 to 02/24/26 showed no consent from the start of care date of 05/01/25. On 02/19/26 at 10:56 a.m., consent form from 05/01/25 was requested and yielded no results. At 12:00 p.m., Staff C stated the consent form was not found. Patient #8 A review of a plan of care dated 10/28/25 to 12/26/25 showed no consent from the start of care date of 10/28/25. On 02/19/26 at 11:15 a.m., consent form from 10/28/25 was requested and yielded no results. At 12:00 p.m., Staff C stated the consent form was not found. Patient #10 A review of a plan of care dated 12/14/25 to 02/11/26 showed no consent from the start of care date of 12/14/25. On 02/19/26 at 11:15 a.m., consent form from 12/14/25 was requested and yielded no results. At 12:00 p.m., Staff C stated the consent form was not found.

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 reviews and interviews, the agency failed to ensure an initial assessment was conducted within 48 hours of referral for two (Patients #5 and #9) of 10 patients. Findings: Patient #5 A review of the clinical record showed the agency received referral information on 03/25/25 and the initial assessment occurred on 05/01/25. The documentation showed no patient refusal of initial assessment, no physician notification of a delay in assessment and no change in orders. On 02/19/26 at 10:56 a.m., Staff C stated the initial assessment was not conducted within 48 hours of referral. Patient #9 A review of the clinical record showed the agency received referral information on 07/25/25 and the initial assessment occurred on 07/28/25. The documentation showed no patient refusal of initial assessment, no physician notification of a delay in assessment and no change in orders. On 02/19/26 at 10:56 a.m., Staff C stated the initial assessment was not conducted within 48 hours of referral.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure patient case conferences were carried out as discharge planning activities for four (Patients #1, 2, 3 and #5) of 10 patients. Findings: Patient #1 A review of the clinical record showed a case conference date of 02/12/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:40 a.m., Staff C stated the conference was not conducted. Patient #2 A review of the clinical record showed a case conference date of 02/12/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:42 a.m., Staff C stated the conference was not conducted. Patient #3 A review of the clinical record showed a case conference date of 02/12/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:48 a.m., Staff C stated the conference was not conducted. Patient #5 A review of the clinical record showed a case conference date of 02/05/26 was ‘not started’ in the eMR system and showed no coordination of care or communication notes of why the case conference was not conducted. On 02/19/26 at 10:56 a.m., Staff C stated the conference was not conducted.

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 reviews and interviews, the agency failed to ensure individualized patient POC included: Identified wound care site for one (Patient #1) of 10 patients. Physical therapy interventions for one (Patient #4) of 10 patients. Weight reporting parameters for one (Patient #6) of 10 patients. Goals for pain management interventions for one (Patient #7) of 10 patients. Skilled nursing interventions for one (Patient #8) of 10 patients. Pain reporting parameters for one (Patient #9) of 10 patients. Findings: Patient #1 A review of the POC dated 12/31/25 to 02/28/26 showed orders for SN to conduct wound site care and assessment every visit. The wound care orders did not identify the location of the wound site. SN visits for wound site care and assessment were conducted on 01/02/26, 01/05/26, 01/09/26, 01/12/26, 01/16/26, 01/19/26, 01/25/26, 01/28/26, 01/30/26, 02/02/26, 02/06/26 and 02/09/26. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 10:40 a.m., Staff C stated the wound care orders did not identify the location of the wound site. Patient #4 A review of the POC dated 01/20/26 to 03/20/26 showed orders for physical therapy to evaluate and establish a treatment plan with a frequency of one time a week for one week, two times a week for three weeks, then one time a week for one week. The POC orders showed no physical therapy interventions. PT visits were conducted on 01/22/26, 01/28/26, 01/31/26, 02/04/26 and 02/09/26. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 10:51 a.m., Staff C stated the PT orders did not include physical therapy interventions. Patient #6 A review of the POC dated 01/06/26 to 03/06/26 showed a primary diagnosis of heart failure and orders for SN to assess, instruct and weigh the patient every visit. The POC showed no weight reporting parameters for physician notification. SN visits to assess, instruct and weigh were conducted on 01/08/26, 01/15/26 and on 01/22/26. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 10:58 a.m., Staff C stated the care plan did not include weight reporting parameters. Patient #7 A review of the POC dated 08/21/25 to 10/19/25 showed orders for SN to assess and instruct on management of pain every visit. The POC showed no pain management goals. A SN visits to assess and instruct on management of pain was conducted on 09/05/25. The clinical record showed no physician notifications and no change in orders. On 02/19/26 at 11:01 a.m., Staff C stated the care plan did not include pain goals for the patient. Patient #8 A review of the POC dated 10/28/26 to 12/26/26 showed orders for SN frequency of one time a week for nine weeks. The POC orders showed no nursing interventions. SN visits were conducted on 10/28/26 with a transfer to in-patient services on 11/03/25. The clinical record showed no physician notifications and no change in orders prior to the in-patient transfer. On 02/19/26 at 11:15 a.m., Staff C stated the POC orders did not include nursing interventions. Patient #9 A review of the POC dated 11/25/25 to 01/23/26 showed orders for SN to assess and instruct patient pain level every visit. The POC showed no pain level reporting parameters for physician notification. SN visits were conducted on 12/12/25 with a transfer to in-patient services on 12/21/25. The clinical record showed no physician notifications and no change in orders prior to the in-patient transfer. On 02/19/26 at 11:20 a.m., Staff C stated the care plan did not include pain level reporting parameters.

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 utilization of patient quality indicator data in the QAPI program for all patients and employees. Findings: A review of quality assessment performance improvement records showed no measurements, analysis, tracking or evaluation of patient quality indicator data by the agency in calendar year 2024 and for 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated the QAPI meeting records did not report on the patient quality indicator data.

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 its QAPI program performance improvement projects for calendar year 2024 and for 01/01/25 to 06/30/25 for all patients and employees. Findings: A review of quality assessment performance improvement records showed no follow up or PIP status designation by the agency in calendar year 2024 and for 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated the QAPI records did not show performance improvement project designation or reporting.

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 its infection control program surveillance monitoring was included in QAPI program reporting for calendar years 2024 and 01/01/25 to 06/30/25 for all patients and employees. Findings: A review of quality assessment performance improvement records showed no infection control program surveillance data for calendar year 2024 and 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated the QAPI records did not show infection control program surveillance reporting.

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 conducted weight assessments for two (Patient #1 and #6) of 10 patients. SN conducted edema assessments of one (Patient #3) of 10 patients. PT conducted visits as ordered for one (Patient #4) of 10 patients. SN conducted pain assessments of one (Patient #7) of 10 patients. SN notified physician for diastolic blood pressure less than reporting parameter for one (Patient #10) of 10 patients. Findings: Patient #1 A review of the POC dated 12/31/25 to 02/28/26 showed orders for SN to conduct assessment of the patient’s weight every visit. SN visits were conducted on 01/02/26, 01/05/26, 01/09/26, 01/12/26, 01/16/26, 01/19/26, 01/25/26, 01/28/26, 01/30/26, 02/02/26, 02/06/26 and 02/09/26 showed no assessment of the patient’s weight was conducted, no patient refusal to weigh, no physician notifications and no change in orders. On 02/19/26 at 10:40 a.m., Staff C stated the nurse should have weighed the patient every visit. Patient #3 A review of the POC dated 12/30/25 to 02/27/26 showed orders for SN to conduct assessment of the patient’s edema every visit. SN visits were conducted on 01/07/26, 01/14/26, 01/21/26, 01/26/26, 02/06/26 and 02/12/26 showed no assessment of the patient’s edema, no physician notifications and no change in orders. On 02/19/26 at 10:48 a.m., Staff C stated the nurse should have assessed the patient’s edema every visit. Patient #4 A review of the POC dated 01/20/26 to 03/20/26 showed orders for physical therapy frequency of one time a week for one week, two times a week for three weeks, then one time a week for one week. A review of the clinical record showed during the week of 02/01/26 to 02/07/26 a PT visit was conducted on 02/04/26 (two visits ordered, one visit conducted). A review of the clinical record showed during the week of 02/08/26 to 02/14/26 a PT visit was conducted on 02/09/26 (two visits ordered, one visit conducted). The clinical record showed no missed visits, patient refusal of visits, physician notifications and no change in orders. On 02/19/26 at 10:51 a.m., Staff C stated the PT did not conduct the visits as ordered. Patient #6 A review of the POC dated 01/06/26 to 03/06/26 showed orders for SN to conduct assessment of the patient’s weight every visit. SN visits were conducted on 01/08/26, 01/15/26, 01/22/26, 02/06/26 and 02/10/26 showed no assessment of the patient’s weight conducted, no patient refusal to weigh, no physician notifications and no change in orders. On 02/19/26 at 10:58 a.m., Staff C stated the nurse should have weighed the patient every visit. Patient #7 A review of the POC dated 08/21/25 to 10/19/25 showed orders for SN to assess, instruct on pain management every visit. SN visits were conducted on 09/05/25 showed no assessment of the patient’s pain was conducted, no patient refusal to assess pain, no physician notifications and no change in orders. On 02/19/26 at 11:01 a.m., Staff C stated the nurse should have assessed the patient’s pain. Patient #10 A review of the POC dated 12/14/25 to 02/11/26 showed orders for SN to report patient’s diastolic blood pressure less than 60. A review of a SN visit note dated 12/16/25 showed a diastolic blood pressure of 58 and showed no re-assessment of the patient’s blood pressure, no physician notifications and no change in orders. On 02/19/26 at 11:25 a.m., Staff C stated the nurse should have re-assessed the blood pressure and then notified the physician as ordered.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure visit note documentation was completed for two (Patients #1 and #2) of 10 patients. Findings: Patient #1 A review of the POC dated 12/31/25 to 02/28/26 showed orders for SN to conduct wound site care and assessment every visit. A review of SN visit notes conducted on 01/02/26, 01/05/26, 01/09/26, 01/12/26, 01/16/26, 01/19/26, 01/25/26, 01/28/26, 01/30/26, 02/02/26, 02/06/26 and 02/09/26 showed no wound site assessment or care that was conducted during the visits and documented “wound care per order” on each SN visit note. On 02/19/26 at 10:40 a.m., Staff C stated the nurses should have documented the wound assessment and care that was performed on the patient in every visit note. Patient #2 A review of the POC dated 12/30/25 to 02/27/26 showed orders for PT with a frequency of one time a week for one week, two times a week for four weeks, then one time a week for four weeks. A review of a PT visit note dated 02/11/26 showed the visit was “not started” and showed no patient refusal of visit, PT missed visit, physician notification and no communication notes. On 02/19/26 at 10:42 a.m., Staff C stated the PT should have completed the visit note.

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 participated in its QAPI program for calendar year 2024 and for 01/01/25 to 06/30/25 for all patients and employees. Findings: A review of quality assessment performance improvement records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar year 2024 and for 01/01/25 to 06/30/25. On 02/19/26 at 12:15 p.m., Staff C stated they did not have PT or OT participate in the QAPI program.

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 interviews, the agency failed to ensure a transfer/discharge summary was provided to a receiving service provider for three (Patients #8, 9 and #10) of 10 patients. Findings: Patient #8 A review of the clinical record showed transfer to in-patient services on 11/03/25 and showed no transfer summary was provided to the in-patient provider. A review of the clinical record showed the physician was provided with a transfer summary of care on 11/19/25 (16 days) after the transfer of care. On 02/19/26 at 11:15 a.m., Staff C stated the transfer summary was not sent to the in-patient facility and the physician was sent a copy 16 days later. Patient #9 A review of the clinical record showed transfer to in-patient services on 11/21/25 and showed no transfer summary was provided to the in-patient provider. A review of the clinical record showed the physician was provided with a transfer summary of care on 11/26/25 (5 days) after the transfer of care. On 02/19/26 at 11:20 a.m., Staff C stated the transfer summary was not sent to the in-patient facility and the physician was sent a copy 5 days later. Patient #10 A review of the clinical record showed transfer to in-patient services on 01/26/26 and showed no transfer summary was provided to the in-patient provider. A review of the clinical record showed the physician was provided with a transfer summary of care on 02/11/26 (16 days) after the transfer of care. On 02/19/26 at 11:25 a.m., Staff C stated the transfer summary was not sent to the in-patient facility and the physician was sent a copy 16 days later.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/04/23 to 01/05/23. 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 reviewed for all patients and employees. Findings: A review of administrative records showed a community-based risk assessment which did not identify the agency and showed no date the assessment was developed and implemented and/or was reviewed for the agency, its patient population, or its employees. On 01/05/22 at 4:00 p.m., Staff A stated the AHRA did not identify the agency and showed no date the assessment was developed and implemented and/or was reviewed for the agency.

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 for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency were in place. On 01/05/22 at 4:00 p.m., Staff B stated the agency did not have an Emergency Preparedness Plan nor administrative processes for an integrated emergency preparedness response in place.

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 10/01/20 to 12/31/20; and calendar years 2021 and 01/01/22 to 12/22/22 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for 10/01/20 to 12/31/20; and calendar years 2021 and 01/01/22 to 12/22/22 (a activation of the EP plan on 12/23/22 was documented but showed no staff participation or after action summary response). On 01/05/23 at 4:00 pm, Staff B stated: 1. The agency had no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for 10/01/20 to 12/31/20; and calendar years 2021 and 01/01/22 to 12/22/22 and; 2. An activation of the EP plan on 12/23/22 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 01/04/23 to 01/05/23. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Condition level deficiencies were cited in the following areas: 484.50 Patient rights 484.55 Comprehensive assessment of patients 484.60 Care planning, Coordination of services, Quality of care 484.65 Quality Assessment and Performance Improvement 484.75 Skilled professional services 454.105 Organization and administration of services Glossary: CHHA certified home health aide EP Emergency Preparedness HHA Home Health Agency OT Occupational therapy PIP Performance Improvement Project PT Physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure patients’ rights to have completed assessments, participate in the establishment and revision of a plan of care and be informed of disciplines to provide services with expected frequencies of visits for two (Patients #2 and #3) of eight patients reviewed. The failed practice had the potential to violate the patient rights to have a comprehensive assessment completed and to participate in the planning of services and care for all patients. See tag G434. Based on record review and interview, the agency failed to ensure an advance notice of discharge was provided prior to being discharged from the agency for five (Patients #2, 3, 4, 7 and #8) of eight patients. The failed practice had the potential to violate a patient’s right to be informed of pending discharge and negated opportunity to exercise their right to appeal a decision to discharge from agency services. See tag G452. Based on record reviews and interview, the agency failed to ensure a transfer/discharge summary was completed at the time of patient transfer/discharge for four (Patients #2, 3, 4 and #7) of eight patients. The failed practice had the potential to effect care transition outcomes for all patients. See tag G454. Based on record review and interview, the agency failed to: 1. Show documentation of the problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services for one (Patient #7) of eight patients; 2. Educate the patient on potential health outcomes from discontinued HHA care and services for one (Patient #7) of eight patients; 3. Notify the physician of the patient's behaviors that impeded the HHA from providing care and services for one (Patient #7) of eight patients and; 4. Inform the physician of the patient’s imminent discharge from the HHA for cause for one (Patient #7) of eight patients. The failed practice had the potential to violate a patient’s right to be informed, consent and participate in decisions that could impact their health outcomes and safety related to the provisions of needed care and services. See tag G464. .

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure patients’ rights to have completed assessments, participate in the establishment and revision of a plan of care and be informed of disciplines to provide services with expected frequencies of visits for two (Patients #2 and #3) of eight patients reviewed. The failed practice had the potential to violate the patient rights to have a comprehensive assessment completed and to participate in the planning of services and care for all patients. Findings: Patient #2 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 08/24/22 to 10/26/22. Documentation showed no patient/caregiver participation in a comprehensive assessment and establishment of a POC, no physician notification of the conducted comprehensive OASIS assessment on 08/24/22 and documented no physician orders. On 01/05/23 at 2:20 p.m., Staff B stated: 1. Patient #2 had a start of care comprehensive assessment (OASIS) on 08/24/22 which was not completed; 2. Patient #2 did not have a POC (physician orders) for the episode period of 08/24/22 to 10/26/22; 3. The patient received agency services without physician orders and; 4. Was discharged from agency services without a visit (desk discharge) and without notice on 10/24/22 and was backdated to 10/14/22 when no episodic POC was realized. Patient #3 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 07/09/22 to 09/06/22. Documentation showed no patient/caregiver participation in a comprehensive assessment and establishment of a POC, no physician notification of the conducted comprehensive (recertification) OASIS assessment on 07/06/22 and documented no physician orders. On 01/05/23 at 2:25 p.m., Staff B stated: 1. Patient #3 had a recertification comprehensive assessment (OASIS) on 08/24/22 which was not completed; 2. Patient #3 did not have a POC (physician orders) for the episode period of 07/09/22 to 09/06/22; 3. Received agency services without physician orders and; 4. Was discharged from agency services without a visit (desk discharge) and without notice on 09/06/22 when no episodic POC was realized.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: 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 at the time of patient transfer/discharge for five (Patients #2, 3, 4, 7 and #8) of eight patients. The failed practice had the potential to effect care transition outcomes for all patients. Findings: Patient #2 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 08/24/22 to 10/26/22. Documentation showed no completion of comprehensive OASIS assessment and establishment of a POC, no physician notification of the conducted comprehensive OASIS assessment on 08/24/22 and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/24/22 and was backdated to 10/14/22 and showed no documentation a discharge summary was completed and provided to the physician of record. On 01/05/23 at 2:20 p.m., Staff B stated: 1. Patient #2 was discharged from agency services without a visit (desk discharge) and without notice on 10/14/22 and; 2. No discharge summary was completed and sent to the physician of record. Patient #3 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 07/09/22 to 09/06/22. Documentation showed no patient/caregiver participation in a comprehensive assessment and establishment of a POC, no physician notification of the conducted comprehensive (recertification) OASIS assessment on 07/06/22 and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 09/06/22 and showed no documentation a discharge summary was completed and provided to the physician of record. On 01/05/23 at 2:25 p.m., Staff B stated: 1. Patient was discharged from agency services without a visit (desk discharge) and without notice on 09/06/22 and; 2. No discharge summary was completed and sent to the physician of record. Patient #4 A review of the POC for 08/06/22 to 10/04/22 showed no completion of a recertification comprehensive OASIS assessment and establishment of a POC was conducted in the last five days of the certification period and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/03/22 and showed no documentation a discharge summary was completed and provided to the physician of record. On 01/05/23 at 2:30 p.m., Staff B stated: 1. Patient #2 was discharged from agency services without a visit (desk discharge) and without notice on 10/03/22 and; 2. No discharge summary was completed and sent to the physician of record. Patient #7 A review of the clinical record showed the patient was discharged from the agency on 10/28/22 for non-compliance. Documentation showed no discharge summary was completed and provided to the physician of record. On 01/05/23 at 2:40 p.m., Staff B stated no discharge summary was completed and sent to the physician of record. Patient #8 A review of the POC for 06/19/22 to 08/17/22 showed no completion of a recertification comprehensive OASIS assessment and establishment of a POC was conducted in the last five days of the certification period and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/25/22 and showed no documentation a discharge summary was completed and provided to the physician of record. On 01/05/23 at 2:45 p.m., Staff B stated: 1. Patient #8 was discharged from agency services without a visit (desk discharge) and without notice on 10/25/22 and; No discharge summary was completed and sent to the physician of record.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an advance notice of discharge was provided prior to being discharged from the agency for five (Patients #2, 3, 4, 7 and #8) of eight patients. The failed practice had the potential to violate a patient’s right to be informed of pending discharge and negated opportunity to exercise their right to appeal a decision to discharge from agency services. Findings: Patient #2 A review of the clinical record showed the patient was discharged without a visit (desk discharge) on 10/24/22 and was backdated to 10/14/22 and showed no documentation of an advance notice of discharge prior to discharge from the agency. Patient #3 A review of the clinical record showed the patient was discharged without a visit (desk discharge) on 09/06/22 and showed no documentation of an advance notice of discharge prior to discharge from the agency. Patient #4 A review of the clincial record showed the patient was discharged without a visit (desk discharge) on 10/03/22 and showed no documentation of an advance notice of discharge prior to discharge from the agency. Patient #7 A review of the clinical record showed the patient was discharged from the agency on 10/28/22 for non-compliance and showed no documentation of an advance notice of discharge prior to discharge from the agency. Patient #8 A review of the clinical record showed the patient was discharged without a visit (desk discharge) on 10/25/22 and showed no documentation of an advance notice of discharge prior to discharge from the agency. On 01/05/23 at 2:45 p.m., Staff B stated Patients #2, 3, 4, 7 and #8 received no advance notice of discharge prior to their discharge from agency services.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Show documentation of the problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services for one (Patient #7) of eight patients; 2. Educate the patient on potential health outcomes from discontinued HHA care and services for one (Patient #7) of eight patients; 3. Notify the physician of the patient's behaviors that impeded the HHA from providing care and services for one (Patient #7) of eight patients and; 4. Inform the physician of the patient’s imminent discharge from the HHA for cause for one (Patient #7) of eight patients. The failed practice had the potential to violate a patient’s right to be informed, consent and participate in decisions that could impact their health outcomes and safety related to the provisions of needed care and services. Findings: Patient #7 A review of a plan of care for 09/01/22 to 10/30/22 showed a SN visit frequency of one time a week for nine weeks, for SN to assess and teach pain management, assess and perform wound care to pressure ulcer wound sites, assess and report changes in respiratory status, medication management and effectiveness and instruct on infection control precautions. SN narrative notes from the recertification assessment for the episodic period 09/01/22 to 10/30/22 stated the patient lived in “deplorable/unsafe living conditions with unstable roommates” and was in process of attempting to move into a skilled nursing facility for residential care. Documentation from the recertification assessment stated the patient continued to require skilled nursing assessment and intervention to be provided by the home health agency and; the patient had good/poor family and friend community support. SN visit notes dated 10/06/22, 10/13/22 and 10/20/22 all repetitively stated the patient living conditions were poor; presented with soiled clothing and socks; home floor had animal feces, trash and spoiled food on it; and patient was advised to call the agency with needs, questions or concerns. Documentation showed no identified problems encountered by the HHA related to behaviors or conditions that impeded the HHA from providing care and services, no communication or education attempts to the patient for potential health outcomes resulting from discontinued HHA care and services, no physician notification of the patient's behaviors and living conditions that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 10/28/22. On 01/05/23 at 2:40 p.m., Staff B stated there was no documentation of: 1. Problems encountered by the HHA related to behaviors and conditions that impeded the HHA from providing care and services; 2. Patient education of potential health outcomes from discontinued HHA care and services; 3. Physician notification of the patient's behaviors and living conditions that impeded the HHA from providing care and services and; 4. Physician notification of the patient’s imminent discharge from the HHA for cause.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure a recertification (updated comprehensive [OASIS]) assessment was completed for two (Patient #4 and #8) of eight patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs and outcomes for all patients. See tag G546. Based on record review and interview, the agency failed to ensure a discharge (updated [OASIS]) assessment was completed at the time of discharge prior to or by the end of the patient’s episodic certification period from agency services for three (Patients #2, 3 and #8) of eight patients. The failed practice had the potential to impact the patient’s progress in meeting care plan goals for all patients. See tag G550. .

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a recertification (updated comprehensive [OASIS]) assessment was completed for two (Patient #4 and #8) of eight patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs and outcomes for all patients. Findings: Patient #4 A review of the POC for 08/06/22 to 10/04/22 showed no completion of a recertification comprehensive OASIS assessment and establishment of a POC was conducted in the last five days of the certification period and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/03/22. On 01/05/23 at 2:30 p.m., Staff B stated Patient #2 did not have a recertification comprehensive OASIS assessment in the last five days of the episodic period of 08/06/22 to 10/04/22. Patient #8 A review of the POC for 06/19/22 to 08/17/22 showed no completion of a recertification comprehensive OASIS assessment and establishment of a POC was conducted in the last five days of the certification period and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/25/22 and showed no documentation a discharge summary was completed and provided to the physician of record. On 01/05/23 at 2:45 p.m., Staff B stated Patient #8 did not have a recertification comprehensive OASIS assessment in the last five days of the episodic period of 06/19/22 to 08/17/22.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge (updated [OASIS]) assessment was completed at the time of discharge prior to or by the end of the patient’s episodic certification period from agency services for three (Patients #2, 3 and #8) of eight patients. The failed practice had the potential to impact the patient’s progress in meeting care plan goals for all patients. Findings: Patient #2 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 08/24/22 to 10/26/22. Documentation showed no completion of comprehensive OASIS assessment and establishment of a POC, no physician notification of the conducted comprehensive OASIS assessment on 08/24/22 and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/24/22 effective 10/14/22. On 01/05/23 at 2:20 p.m., Staff B stated Patient #2 was discharged from agency services without a visit (desk discharge) and without notice on 10/24/22 effective 10/14/22. Patient #3 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 07/09/22 to 09/06/22. Documentation showed no patient/caregiver participation in a comprehensive assessment and establishment of a POC, no physician notification of the conducted comprehensive (recertification) OASIS assessment on 07/06/22 and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/24/22 backdated to 09/06/22. On 01/05/23 at 2:25 p.m., Staff B stated Patient #3 was discharged from agency services without a visit (desk discharge) and without notice on 10/24/22 backdated to 09/06/22. Patient #8 A review of the POC for 06/19/22 to 08/17/22 showed documentation no completion of a recertification comprehensive OASIS assessment and establishment of a POC was conducted in the last five days of the certification period and documented no physician orders. Documentation showed the patient was discharged without a visit (desk discharge) on 10/25/22 and backdated to 08/15/22. On 01/05/23 at 2:45 p.m., Staff B stated Patient #8 was discharged from agency services without a visit (desk discharge) and without notice on 10/25/22 backdated to 08/15/22.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of an episodic Plan of Care after a comprehensive OASIS assessment for two (Patients #2 and #3) of eight patients. The failed practice had the potential to effect a patient’s response to health care interventions to achieve functional and physical health improvements for all patients. See tag G572. Based on record review and interview, the agency failed to ensure: An individualized patient POC included pain reporting parameters for two (Patients #2 and #4) of eight patients and; An individualized patient POC included weight reporting parameters for one (Patient #6) of eight patients.The failed practice had the potential to effect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. See Tag G574. Based on record reviews and interview, the agency failed to ensure: 1. SN visits were ordered by the physician for two (Patients #2 and #3) of eight patients and; 2. CHHA visits were ordered by the physician for one (Patient #3) of eight patients.The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services ordered by their physician for all patients. See tag G580. .

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 development of an episodic Plan of Care after a comprehensive OASIS assessment for two (Patients #2 and #3) of eight patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve functional and physical health improvements for all patients. Findings: Patient #2 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 08/24/22 to 10/26/22. Documentation showed no physician notification of the conducted comprehensive OASIS assessment on 08/24/22 and documented no physician orders. On 01/05/23 at 2:20 p.m., Staff B stated Patient #2: 1. did not have a POC (physician orders) for the episode period of 08/24/22 to 10/26/22; 2. received agency services without physician orders and; 3. was discharged from agency services without a visit (desk discharge) on 10/24/22 backdated to 10/14/22 when no episodic POC was realized. Patient #3 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 07/09/22 to 09/06/22. Documentation showed no physician notification of the conducted comprehensive (recertification) OASIS assessment on 07/06/22 and documented no physician orders. On 01/05/23 at 2:25 p.m., Staff B stated Patient #3: 1. did not have a POC (physician orders) for the episode period of 07/09/22 to 09/06/22; 2. received agency services without physician orders and; 3. was discharged from agency services without a visit (desk discharge) on 10/24/22 backdated to 09/06/22 when no episodic POC was realized.

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: 1. An individualized patient POC included pain reporting parameters for two (Patients #2 and #4) of eight patients and; 2. An individualized patient POC included weight reporting parameters for one (Patient #6) of eight patients. The failed practice had the potential to affect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. Findings: Patient #2 A review of a POC dated 10/27/22 to 12/25/22, showed orders for a SN visit frequency of one time a week for three weeks, then once every other week for six weeks for SN to assess, instruct, monitor and report to the physician the patient’s pain level. Documentation showed no physician pain reporting parameters on the POC. Documentation showed patient reported pain levels during SN visits dated 10/31/22 reported pain level of 3; 11/07/22 reported pain level of 2; and on 12/05/22 reported pain level of 3. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 01/05/23 at 2:25 p.m., Staff B stated the POC for patient #2 should have included physician pain reporting parameters. Patient #4 A review of the POC dated 11/07/22 to 01/05/23 showed orders for a SN visit frequency of one time a week for nine weeks for SN to assess, instruct, monitor and report to the physician the patient’s pain level. Documentation showed no physician pain reporting parameters on the POC. Documentation showed patient reported pain levels during SN visits dated 11/21/22 reported pain level of 3; 11/28/22 reported pain level of 3; 12/08/22 reported pain level of 3; 12/19/22 reported pain level of 3 and on 12/27/22 reported pain level of 3. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 01/05/23 at 2:25 p.m., Staff B stated the POC for patient #4 should have included physician pain reporting parameters. Patient #6 A review of the POC dated 10/14/22 to 12/12/22 showed orders for SN to conduct assessment and monitoring of patient weight every visit and notify the physician of change in patient weight. Documentation showed physician weight reporting parameters on the POC. Documentation showed SN visits were conducted on 10/17/22, 10/29/22 and on 10/31/22 and showed no patient weight monitoring was conducted. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 01/05/23 at 2:35 p.m., Staff B stated: 1. the SN should have been conducted assessment and monitoring of the patient’s weight every visit as ordered by the physician and; 2. The POC for patient #4 should have included physician weight reporting parameters.

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 reviews and interview, the agency failed to ensure: 1. SN visits were ordered by the physician for two (Patients #2 and #3) of eight patients and; 2. CHHA visits were ordered by the physician for one (Patient #3) of eight patients. The failed practice had the potential to impact the health, safety and well-being of patients to receive appropriate care and services ordered by their physician for all patients. Findings: Patient #2 A review of the clinical record showed no documentation of physician orders for a POC episode period of 08/24/22 to 10/26/22. Documentation showed SN visits were conducted on 09/07/22, 09/15/22, 09/21/22, 09/28/22, 10/03/22 and on 10/13/22 (six SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 01/05/23 at 2:20 p.m., Staff B stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN and CHHA visits were conducted without orders for patient #2. Patient #3 A review of the clinical record showed no documentation of physician orders for a POC episode period of 07/09/22 to 09/06/22. Documentation showed SN visits were conducted on 07/11/22, 07/18/22, 07/25/22, 08/01/22, 08/03/22, 08/08/22, 08/11/22, 08/15/22, 08/17/22, 08/22/22, 08/24/22, 08/25/22, 08/31/22 and on 09/02/22 (14 SN visits conducted, no visits ordered [no episodic POC]); and CHHA visits were conducted on 07/12/22, 07/14/22, 07/19/22, 07/21/22, 07/26/22, 07/28/22, 08/02/22, 08/04/22, 08/09/22, 08/11/22, 08/16/22, 08/18/22, 08/23/22, 08/25/22, 08/30/22 and on 09/01/22 (16 CHHA visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN and CHHA visits and documented no orders. On 01/05/23 at 2:25 p.m., Staff B stated physician orders should have been obtained and documented prior to the SN and CHHA visits; and the physician should have been notified the SN and CHHA visits were conducted without orders for patient #3.

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 evidence of a patient centered QAPI Program for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G642. Based on record review and interview, the agency failed to show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See tag G644. Based on record review and interview, the agency failed to show conduction of patient centered QAPI Program activities for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G646. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 10/01/20 to 12/31/20 and in calendar years 2020 and 2021 for all patients and employees. The failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See tag 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. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. See tag G660. .

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 all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: Administrative records of ongoing patient centered QAPI program for the agency from 10/01/20 to 12/31/20; and calendar years 2021 and 2022 were requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated there was no documentation of an ongoing QAPI program to improve the care, services, and operations of the agency from 10/01/20 to 12/31/20; and calendar years 2021 and 2022.

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 of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: Administrative records of ongoing patient centered QAPI program for the agency which showed data collection activities utilized in the agency's QAPI Program from 10/01/20 to 12/31/20; and calendar years 2021 and 2022 were requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated: 1. there was no documentation of an ongoing QAPI program to improve the care, services, and operations of the agency from 10/01/20 to 12/31/20; and calendar years 2021 and 2022 and 2. no program improvement data and no analysis of collected data that showed improved quality of patient care for 10/01/20 to 12/31/20; and calendar years 2021 and 2022.

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 show conduction of patient centered QAPI Program activities for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of QAPI program activities to improve the care, services, and operations of the agency from 10/01/20 to 12/31/20; and calendar years 2021 and 2022 were requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated there was no documentation of ongoing QAPI program activities to improve the care, services, and operations of the agency from 10/01/20 to 12/31/20; and calendar years 2021 and 2022.

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 10/01/20 to 12/31/20 and in calendar years 2021 and 2022 for all patients and employees. The failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of a QAPI program PIP from 10/01/20 to 12/31/20; and calendar years 2021 and 2022 were requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated there was no documentation of ongoing QAPI program PIPs from 10/01/20 to 12/31/20; and calendar years 2021 and 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 governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: Administrative records which showed governing body oversite of the conduction of patient centered QAPI Program activities from 10/01/20 to 12/31/20; and calendar years 2021 and 2022 were requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated there was no documentation which showed governing body oversite of the conduction of patient centered QAPI Program activities from 10/01/20 to 12/31/20; and calendar years 2021 and 2022.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure its infection control program included surveillance monitoring and reporting; and was included in QAPI program activities for all patients and staff. The failed practice placed the agency at risk for missed opportunities to identify and reduce the incidence and occurrence of infection throughout the agency and effect the health and well-being of all patients and employees. See tag G684. .

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 its infection control program included surveillance monitoring and reporting; and was included in QAPI program activities for all patients and staff. The failed practice placed the agency at risk for missed opportunities to identify and reduce the incidence and occurrence of infection throughout the agency and effect the health and well-being of all patients and employees. Findings: Administrative records which showed documentation of the agency’s infection control program and its surveillance data was included in QAPI program activities for 10/01/20 to 12/31/20 and calendar years 2021 and 2022 was requested. No documentation was provided. . On 01/05/23 at 9:40 a.m., Staff A stated there was no documentation which showed the agency’s infection control program, and its surveillance data was included in QAPI program activities from 10/01/20 to 12/31/20; and calendar years 2021 and 2022.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on a record review and interview, the agency failed to ensure an agency staff participation compliance rate with COVID 19 vaccination and/or exemption requirements of 100% for all patients and staff. Findings: Review of administrative records for agency staff participation compliance rate with COVID 19 vaccination or exemption status showed documentation that three of nine active employees showed no vaccination or vaccination exemption status resulting in an agency compliance rate of 66%. On 01/05/23 at 3:00 p.m., Staff A stated the administrative records for COVID 19 vaccination or exemption status were provided in their entirety and documentation showed the agency did not meet the required participation compliance rate of 100%.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the POC’s: 1. SN to perform PICC line care every visit (weekly) for one (Patient #1) of eight patients; 2. PT evaluations were conducted for one (Patient #1) of eight patients; 3. OT evaluations were conducted for two (Patients #1 and #2) of eight patients; 4. OT to conduct visit frequencies as ordered by the physicians for one (Patients #1) of eight patients; 5. SN to conduct visit frequencies as ordered by the physicians for two (Patients #2 and #3) of eight and; 6. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for one (Patients #6) of eight patients. The failed practice had the potential to place patients at risk for poor health outcomes by not receiving care and services as ordered by their physicians. See tag G710. 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. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G720. .

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 services were provided as ordered on the POC’s: 1. SN to perform PICC line care every visit (weekly) for one (Patient #1) of eight patients; 2. PT evaluations were conducted for one (Patient #1) of eight patients; 3. OT evaluations were conducted for two (Patients #1 and #2) of eight patients; 4. OT to conduct visit frequencies as ordered by the physicians for one (Patients #1) of eight patients; 5. SN to conduct visit frequencies as ordered by the physicians for two (Patients #2 and #3) of eight and; 6. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for one (Patients #6) of eight patients. The failed practice had the potential to place patients at risk for poor health outcomes by not receiving care and services as ordered by their physicians. Findings: Patient #1 A review of the POC dated 10/30/22 to 12/28/22 showed orders for SN to conduct care of an intravenous access device (PICC) line every visit. Documentation showed no intravenous access device (PICC) line care was conducted during SN visits on 12/14/22 and on 12/19/22. Documentation showed no patient/caregiver refusal of intravenous access device (PICC) line care and assessment and no change in orders. POC showed orders for PT and OT to evaluate and treat with 6 visits each. Documentation showed no PT or OT evaluation was conducted prior to an inpatient hospital transfer on 11/20/22 (21 days from the effective date of the POC order to the date of the IP transfer). Documentation showed no patient/caregiver refusal of the PT or OT evaluations, no physician notifications and no changes in orders. Review of a resumption of care POC dated 12/08/22 showed an OT visit frequency of one time a week for one week, two times a week for two weeks, and then one time a week for one week. During the weeks of 12/18/22 to 12/24/22 (two visits ordered, two visits missed) and 12/25/22 to 12/28/22 (two visits ordered, one visit missed). Documentation showed no patient/caregiver refusal of the OT visits, no physician notifications and no changes in orders. On 01/05/23 at 2:15 p.m., Staff B stated: 1. The PICC line had not been discontinued at the time of the visits and the PICC line assessment and care should have been conducted at the time of the SN visit and; 2. The PT and OT evaluations should have been conducted prior to the inpatient transfer date and; 3. The OT visits should have been conducted as ordered after the evaluation was completed. Patient #2 A review of a POC dated 10/27/22 to 12/25/22, showed orders for a SN visit frequency of one time a week for three weeks, then once every other week for six weeks. Documentation showed during the week 12/18/22 to 12/24/22 no SN visit was conducted (one visit ordered, one visit missed); and review of a verbal order dated 11/11/22 showed orders for OT evaluation and treatment. Documentation showed no OT evaluation was conducted. Documentation showed no attempts to complete the OT evaluation, no patient/caregiver refusal of the OT evaluation or SN visit, no physician notifications and no change in orders. On 01/05/23 at 2:25 p.m., Staff B stated the SN should have conducted the SN visit and the OT evaluation should have been provided and conducted by the agency. Patient #3 A review of the POC dated 10/24/22 to 12/22/22 showed orders for a SN visit frequency of two times a week for two weeks, three times a week for seven weeks, and then one time a week for two weeks. Documentation showed during the weeks of 11/06/22 to 11/12/22 (three visits ordered, one visit missed); 11/13/22 to 11/19/22 (three visits ordered, one visit missed); 11/20/22 to 11/26/22 (three visits ordered, one visit missed); 11/27/22 to 12/03/22 (three visits ordered, one visit missed); 12/04/22 to 12/10/22 (three visits ordered, one visit missed) and 12/11/22 to 12/17/22 (three visits ordered, one visit missed). Documentation showed no patient/caregiver refusal of SN visits, no physician notifications and no change in orders. On 01/05/23 at 2:30 p.m., Staff B stated the SN visit frequency should have been conducted as ordered by the physician. Patient #6 A review of the POC dated 10/14/22 to 12/12/22 showed orders for SN to conduct assessment and monitoring of patient weight every visit and notify the physician of change in patient weight. Documentation showed no assessment and monitoring of the patient’s weight was conducted during SN visits on 10/17/22 and on 10/24/22. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 01/05/23 at 2:35 p.m., Staff B stated the SN should have been conducted assessment and monitoring of the patient’s weight every visit as ordered by the physician.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. CHHA visit notes were completed for one (Patients #3) of eight patients and; 2. SN visit notes were completed for one (Patients #6) of eight patients. Findings: Patient #3 A plan of care dated 10/24/22 to 12/22/22 documented a principal diagnosis of Diabetes Mellitus Type II with foot ulcer. Documentation showed a CHHA visit frequency of two times a week for nine weeks. Documentation showed CHHA visits notes on 11/22/22 and on 12/06/22 were not started, completed and authenticated by the CHHA. On 01/05/22 at 2:25 p.m., Staff B stated visit notes are to be completed and signed by staff within 24 hour of the visit. Patient #6 A plan of care dated 10/14/22 to 12/12/22 documented a principal diagnosis of stage 4 pressure ulcer. Documentation showed a SN visit frequency of one times a week for nine weeks. Documentation showed SN visits note on 10/24/22 was not started, completed and authenticated by the SN. On 01/05/22 at 2:35 p.m., Staff B stated visit notes are to be completed and signed by staff within 24 hours of the visit.

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. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: Administrative records of multi-disciplined skilled professional staff participation in the agency’s QAPI program from 10/01/20 to 12/31/20; and calendar years 2021 and 2022 were requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated there was no documentation which showed evidence of an ongoing QAPI program activities to improve the care, services, and operations of the agency from 10/01/20 to 12/31/20; and calendar years 2021 and 2022.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for 10/01/20 to 12/31/20, calendar year's 2021 and 2022; and 3. Agency program evaluation for 10/01/20 to 12/31/20; and calendar years 2021 and 2022 effecting all patients and staff. This failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. See tag G942. Based on record review and interview, the agency failed to ensure governing body appointment of the administrator for the agency effecting all patients and staff. This failed practice had the potential to effect day to day operational oversite responsibilities of the agency impacting the services its patients received from its staff. See tag G 946. Based on record review and interview, the agency failed to ensure operational oversight of the agency by the administrator and governing body for 22 patients and all staff. The failed practice effected the agency’s ability to effectively operate and provide appropriate care and services to its patient’s and the community at large. See tag G948. Based on record review and interview, the agency failed to ensure governing body appointment of the clinical manager and/or supervising RN for the agency effecting all patients and staff. This failed practice had the potential to effect the care services provided by the agency and the subsequent care outcomes of the patients; and provide adequate clinical supervisory oversite of its staff. See tags G954 and G958. .

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. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for 10/01/20 to 12/31/20, calendar year's 2021 and 2022; and 3. Agency program evaluation for 10/01/20 to 12/31/20; and calendar years 2021 and 2022 effecting all patients and staff. This failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. Findings: Administrative records which showed governing body over-site and responsibility for the agency from 10/01/20 through 01/04/23 was requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated there was no administrative records which showed evidence of ongoing governing body oversite and responsibility for the agency.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of the administrator for the agency affecting all patients and staff. This failed practice had the potential to affect day to day operational oversite responsibilities of the agency impacting the services its patients received from its staff. Findings: Administrative records of governing body over-site of the agency from 10/01/20 through 01/04/23 was requested; including appointment of the administrator for the agency. No documentation was provided. On 01/04/23 at 11:30 p.m., Staff A stated she was administrator of the agency since a hire date of 11/08/22. On 01/05/23 at 9:40 a.m., Staff A stated there were no governing body administrative records which showed evidence of ongoing governing body oversite and appointment of the administrator for the agency.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure operational oversight of the agency by the administrator and governing body for 22 patients and all staff. The failed practice affected the agency’s ability to effectively operate and provide appropriate care and services to its patient’s and the community at large. Findings: On 01/04/23 at 10:55 a.m., an announced on-site visit to the agency was conducted for survey purposes. A list of discharged patients in the last six months was requested. At 11:15 a.m., Staff B stated multiple patients were discharged from the agency in October 2022 for no follow up reassessment OASIS and/or no discharge OASIS was conducted by the Clinical Manager/Supervising RN of record at that time (name withheld) for the agency; and services were provided without physician orders and/or a Plan of Care during the episode periods for the affected patients. Staff B further stated the discharge OASISs (desk discharge) entered for the affected patients auto backdated the discharge entry date to the last SN visit date of record instead of the actual entry date the OASISs were conducted (entered desk discharge). Administrative and related clinical records were requested. Review of an administrative record showed documentation that 10 patients (Patients #8, 9, 11, 12, 14, 15, 18, 19, 20 and #21) were discharged due to no POC after comprehensive OASIS assessment, no follow up recertification OASIS assessment or no discharge OASIS assessment conduction by the end of the episode periods. Documentation showed discharge OASISs for the 10 discharged patients were auto backdated by the electronic documentation electronic medical record system to the last SN visit date of record for each of the patients and the clinical records did not show the actual discharge date the discharge OASIS (desk discharge) entries were conducted. Review of an administrative record showed documentation that nine patients (Patients #1, 2, 3, 4, 10, 13, 16, 17 and #22) were discharged and readmitted to agency services for no POC after comprehensive OASIS assessment, no follow up recertification OASIS assessment or no discharge OASIS assessment conduction by the end of the episode periods. Documentation showed discharge OASISs for the nine discharged patients were auto backdated by the electronic documentation electronic medical record system to the last SN visit date of record for each of the patients and the clinical records did not show the actual discharge date the discharge OASIS (desk discharge) entries were conducted. Administrative records which showed operational oversight of the agency by the administrator from 10/01/20 through 11/08/22 and agency case conference and/or discharge planning coordination reports for the effected 19 discharged patients were requested. No documentation was provided. On 01/05/23 at 9:40 a.m., Staff A stated there was no documentation which showed evidence of ongoing day to day operational oversight for the agency by the administrator of record from 10/01/20 to 11/08/22; and no agency incidents or error reports or case conference/discharge planning reports were documented.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of the clinical manager and/or supervising RN for the agency effecting all patients and staff. This failed practice had the potential to affect the care services provided by the agency impacting subsequent care outcomes of the patients and provide adequate clinical supervisory oversite of its staff. Findings: Administrative records of governing body over-site of the agency from 10/01/20 through 01/04/23 was requested; including appointment of the clinical manager and/or supervising RN for the agency. No documentation was provided. On 01/04/23 at 10:55 a.m., Staff B stated she was the director of nurses (clinical manager) for the agency since 11/01/22. On 01/05/23 at 9:40 a.m., Staff A stated there was no governing body administrative records which showed evidence of ongoing governing body oversite and appointment of the director of nurses (clinical manager) for the agency.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of the alternate clinical manager and/or alternate supervising RN for the agency effecting all patients and staff. This failed practice had the potential to affect the care services provided by the agency and the subsequent care outcomes of the patients; and provide adequate clinical supervisory oversite of its staff. Findings: Administrative records of governing body over-site of the agency from 10/01/20 through 01/04/23 was requested; including appointment of the alternate clinical manager and/or alternate supervising RN for the agency. No documentation was provided. On 01/04/23 at 10:55 a.m., Staff B stated she was the director of nurses (clinical manager) for the agency since 11/01/22. At 11:30 p.m., Staff A stated she was alternate director of nurses (supervising RN; clinical manager) for the agency since a hire date of 11/08/22. On 01/05/23 at 9:40 a.m., Staff A stated there was no governing body administrative records which showed evidence of ongoing governing body oversite and appointment of the director of nurses (clinical manager) for the agency.

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 for two (Patients #1 and #6) of eight patients. Findings: Patient #1 A review of the clinical record documented transfer from the agency on 11/20/22 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. Patient #6 A review of the clinical record documented discharge from the agency on 10/31/22. Documentation showed no discharge summary was provided to the physician service provider. On 01/05/23 at 2:15 p.m., Staff B stated: 1. No transfer summary was sent to the receiving service providers for Patient #1 and; 2. No discharge summary was sent to the physician for Patient #6.