Every finding on record at Osage Nation Enterprises Incorporated

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/01/24 to 10/02/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/01/24 to 10/02/24. An entrance conference was conducted with Staff A. Staff C was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Deficiencies were cited as a result of the re-certification survey.

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 an individualized plan of care for six (Patient #1, 2, 3, 4, 5 and 6) of eight patients. Patient #1 A review of the plan of care dated 07/27/24 to 09/24/24 showed a primary diagnosis of acute on chronic systolic (congestive) heart failure with no individualized interventions developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 06/06/24 to 08/04/24 showed a primary diagnosis of diabetes mellitus type II with no individualized interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 07/15/24 to 09/12/24 showed a primary diagnosis of diabetes mellitus type II with diabetic kidney complications with no individualized interventions to the management of care of the primary diagnosis. Patient #4 A review of the plan of care dated 07/28/24 to 09/25/24 showed a primary diagnosis of anemia with no individualized interventions to the management of care of the primary diagnosis. Patient #5 A review of the plan of care dated 08/03/24 to 10/01/24 showed a primary diagnosis of unspecified R-bundle branch block with no individualized interventions developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 06/10/24 to 08/08/24 showed a primary diagnosis of hypothyroidism with no individualized interventions to the management of care of the primary diagnosis. On 10/02/24 at 12:20 pm, Staff C stated the plan of care for Patients #1, 2, 3, 4, 5 and 6 were not individualized for the management of the primary diagnosis.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was revised to reflect the presence of wounds for two (Patient #1 and 2) of eight patients. Patient #1 A review of the plan of care dated 07/27/24 to 09/24/24 showed a primary diagnosis of acute on chronic systolic (congestive) heart failure and documented a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A skilled nurse assessment dated 08/23/24 documented the presence of wounds to the left and right buttocks, teaching to encourage methods to decrease pressure to the wounds, the performance of wound care performed with no updates/revisions to the plan of care for the presence, care or treatment of the wounds. A skilled nurse assessment dated 08/26/24 documented the presence of wounds to the left and right buttocks, teaching to encourage methods to decrease pressure to the wounds, the performance of wound care performed with no updates/revisions to the plan of care for the presence, care or treatment of the wounds. A skilled nurse assessment dated 09/03/24 documented the presence of wounds to the left and right buttocks, teaching to encourage methods to decrease pressure to the wounds, the performance of wound care performed with no updates/revisions to the plan of care for the presence, care or treatment of the wounds. A skilled nurse assessment dated 09/13/24 documented the presence of wounds to the left and right buttocks, teaching to encourage methods to decrease pressure to the wounds, the performance of wound care performed with no updates/revisions to the plan of care for the presence, care or treatment of the wounds. Patient #2 A review of the plan of care dated 06/06/24 to 08/04/24 showed a primary diagnosis of diabetes mellitus type II and documented a skilled nurse frequency of every other week. A review of the clinical record showed the following: A skilled nurse assessment dated 06/11/24 documented the presence of wounds to the patients (unspecified toe), the performance of wound care performed with no updates/revisions to the plan of care for the presence, care or treatment of the wounds. A skilled nurse assessment dated 07/09/24 documented the presence of wounds to the patients (unspecified toe), the performance of wound care performed with no updates/revisions to the plan of care for the presence, care or treatment of the wounds. A skilled nurse assessment dated 07/25/24 documented the presence of wounds to the patients (unspecified toe), the performance of wound care performed with no updates/revisions to the plan of care for the presence, care or treatment of the wounds. On 10/02/24 at 12:30 pm., Staff C stated the plan of care for Patients #1 and 2 were not updated to reflect the presence or care of wounds.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 10/07/21 to 10/08/21. A deficiency was 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), §485.625(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 hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 33 patients and all employees. Findings: A review of administrative records showed no community-based risk assessment which addressed the agency and its patient population for the calendar years of 2019, 2020 and January 01, 2021 to October 08, 2021. On 10/08/21 at 11:10 am, Staff B stated there was no documentation of an all hazards risk assessment for the calendar years of 2019, 2020 and January 01, 2021 to October 08, 2021.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/07/21 to 10/08/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff B. Deficiencies were cited as a result of the re-certification survey: GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects QAPI Quality Assessment and Performance Improvement OASIS Outcome and Assessment Information Set

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of OASIS data to improve program effectiveness, quality of patient care and overall program improvement for all 33 current patients. Findings: A review of administrative records showed no OASIS data collection activities utilized in the agency's QAPI Program for calendar years of 2019, 2020 and from January 01, 2021 to October 08, 2021. On 10/08/21 at 10:40 am, Staff B stated they had no analysis of OASIS data available that showed improved quality of patient care for 2019, 2020 and from January 01, 2021 to October 08, 2021.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 33 patients and all employees. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs for the calendar years of 2020 and January 01, 2021 to October 08, 2021. On 10/08/21 at 10:40 am, Staff B stated the agency had no documented PIP activities for 2020 and from January 01, 2021 to October 08, 2021.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all 33 patients and employees. Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities, no patient record audits and no QAPI meetings to improve the care, services and operations of the agency for calendar years 2019, 2020 or for January 01, 2021 to October 08, 2021. On 10/08/21 at 10:40 am, Staff B stated they had no documentation which showed governing body oversite of QAPI program activities for calendar years of 2019, 2020 or for January 01, 2021 to October 08, 2021.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for all patients and staff. Findings: A review of administrative records showed no ongoing infection control surveillance data for calendar year's 2019, 2020 and from January 01, 2021 to October 08, 2021. On 10/08/21 at 11:00 am, Staff B stated the agency had no comprehensive infection surveillance program in place.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure required home health aide annual in-service training hours were completed for one (Staff C) of five personnel records reviewed. Findings: Staff C A review of the personnel record showed no documentation of required 12 hours of annual in-service training for calendar year 2019. On 10/08/21 at 11:00 a.m., Staff B stated the annual in-service training hours for Staff C should have been documented in the personnel record for 2019 but was not.