Every finding on record at Pentadoyen, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/29/24 to 10/31/24. Standard deficiencies were cited as a result of the Emergency Preparedness Program survey.

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 and contact information 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 and/or resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency. On 10/31/24 at 9:05 a.m., Staff B stated the agency did not have an Emergency Preparedness Plan with administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/29/24 to 10/31/24. 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 administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D and E. Standard level deficiencies were cited as a result of the survey. Glossary: CHHA Certified Home Health Aide EP Emergency Preparedness LPN licensed practical nurse POC plan of care QAPI Quality Assessment and Performance Improvement RN registered nurse ROC resumption of care SN skilled nurse SOC start of care

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an advance beneficiary notice was provided prior to discharge from agency services for one (Patient #16) of 17 patients. Findings: Patient #16 A review of the clinical record showed no advance notice of discharge was provided prior to discharge from the agency on 05/16/24. On 10/31/24 at 10:05 a.m., Staff B stated patient #16 was not provided an advance notice of discharge prior to discharge from the agency.

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 review and interview, the agency failed to ensure: 1. A SOC assessment was conducted within 48 hours of referral for six (Patients #2, 3, 4, 5, 7 and #9) of 17 patients; and 2. A SOC assessment was conducted on one (Patient #6) of 17 patients. Findings: Patient #2 A review of the clinical record showed the agency received referral information on 11/16/23 and the SOC assessment occurred on 11/20/23. Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #3 A review of the clinical record showed the agency received referral information on 01/27/23 and the SOC assessment occurred on 02/06/23. Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #4 A review of the clinical record showed the agency received referral information on 06/03/22 and the SOC assessment occurred on 06/08/22. Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #5 A review of the clinical record showed the agency received referral information on 10/27/23 and the SOC assessment occurred on 10/31/23. Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #6 A review of the clinical record showed the agency received referral information on 10/03/24. Documentation showed an LPN SN visit to administer medication was conducted on 10/04/24 but showed no SOC assessment was conducted by an RN. Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 10/31/24 at 9:34 a.m., Staff B stated the patient was seen as one-time cash pay patient and no SOC assessment was conducted. Patient #7 A review of the clinical record showed the agency received referral information on 03/01/23 and the SOC assessment occurred on 03/24/23. Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #9 A review of the clinical record showed the agency received referral information on 10/01/24 and the SOC assessment occurred on 10/04/24. Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 10/31/24 at 9:20 a.m. to 9:44 a.m., Staff B stated the SOC assessments for patients #2, 3, 4, 5, 7 and #9 should have been conducted within 2 days of referral or the SOC date ordered by the physician provider.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile was collected or reviewed for ordered medications for one (Patient #6) of 17 patients. Findings: Patient #6 A review of the clinical record showed the agency received referral information on 10/03/24. Documentation showed an LPN SN visit to administer medication was conducted on 10/04/24 but showed no SOC assessment, and no list of medications cross referenced for allergies and/or drug incompatibilities conducted by an RN. Documentation showed no medication profile (list), no patient refusal of SOC assessment, no physician notifications, and no change in orders. On 10/31/24 at 9:34 a.m., Staff B stated the patient was seen as one-time cash pay patient, and the medication was a one-time dose. Documentation showed no SOC assessment, and no medication list was cross referenced for allergies and/or drug incompatibilities was conducted by an RN.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a ROC (updated comprehensive [OASIS]) assessment after an in-patient stay was completed for one (Patient #15) of 17 patients. Findings: Patient #15 A review of the POC for 04/26/24 to 06/24/24 showed documentation the patient had an in-patient hospital stay from 04/27/24 to 04/28/24. Documentation showed a SN visit was conducted on 04/29/24 but showed no ROC comprehensive (OASIS) assessment and update of the POC was conducted until 05/02/24. Documentation showed no physician orders for the hospital hold from 04/27/24 to 04/28/24, no order for the SN visit on 04/29/24 and no order for the ROC on 05/02/24. On 10/31/24 at 9:56 a.m., Staff B stated Patient #15 did not have a ROC comprehensive (OASIS) assessment until 05/02/24 but should have had a ROC assessment on 04/29/24.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC's included ankle measurement reporting parameter's (alternate to weight monitoring) for one (Patient #8) of 17 patients. Findings: Patient #8 A review of a POC dated 09/17/24 to 11/15/24 documented a principal diagnosis of Diabetes Mellitus Type II and a secondary diagnosis of hypertension with heart failure. Documentation showed no ankle measurement reporting parameter's (alternate to weight monitoring) related to interventions and goals for management of Diabetes Mellitus Type II and hypertension with heart failure. On 10/31/24 at 9:38 a.m., Staff B stated the POC for patient #8 did not include ankle measurement reporting parameters related to the management of the patient's diagnoses of Diabetes Mellitus Type II and hypertension with heart failure.

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 review and interview, the agency failed to ensure: 1. Physician ordered SN visit for administration of an injectable medication for one (Patient #6) of 17 patients; and 2. Physician ordered SN visit for one (Patient #15) of 17 patients. Findings: Patient #6 A review of the clinical record showed the agency received referral information on 10/03/24. Documentation showed an LPN SN visit to administer medication was conducted on 10/04/24. Documentation showed no SOC assessment, no list of medications cross referenced for allergies and/or drug incompatibilities and no physician’s order for a SN visit. On 10/31/24 at 9:34 a.m., Staff B stated: 1. The patient was seen as one-time cash pay patient, and the medication was a one-time dose; and 2. Documentation showed no physician’s order for a SN visit. Patient #15 A review of the POC for 04/26/24 to 06/24/24 showed documentation the patient had an in-patient hospital stay from 04/27/24 to 04/28/24. Documentation showed a SN visit was conducted on 04/29/24 but showed no ROC comprehensive (OASIS) assessment and update of the POC was conducted until 05/02/24. Documentation showed no physician’s order for the SN visit on 04/29/24 and no physician’s order for the ROC on 05/02/24. On 10/31/24 at 9:56 a.m., Staff B stated documentation for patient #15 showed no physician’s orders for the SN visit on 04/29/24 and no physician’s order for the ROC on 05/02/24.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for five (Patients #1, 3, 4, 8 and #11) of 17 patients. Findings: Patient #1 A review of the POC dated 09/26/24 to 11/24/24 showed documentation of SN to review blood sugar log and to conduct a fingerstick blood sugar if the patient has not performed it the day of the visit and report to the physician random fingerstick blood sugar 300. Documentation showed during SN visits dated 09/27/24, 10/01/24, 10/04/24, 10/08/24, 10/18/24, 10/22/24 and 10/25/24 the patient reported he was no longer monitoring his FSBS. Documentation showed no physician communications or coordination of care notes related to patient no longer monitoring his FSBS and showed no changes in orders. On 10/31/24 at 9:15 a.m., Staff B stated the SN should have communicated the patient’s non-compliance to monitor the FSBS with the physician. Patient #3 A review of the POC dated 09/28/24 to 11/26/24 showed documentation of SN to administer the medication, Perseris 120 milligrams intramuscular injection every month due week of 10/04/24. Documentation showed during SN visit dated 10/02/24 (week of 10/04/24) the medication was not available to administer. Documentation showed no physician communications or coordination of care notes related to the medication was not available to administer to the patient and showed no changes in orders. On 10/31/24 at 9:22 a.m., Staff B stated the SN should have communicated the ordered medication was not available to administer with the physician. Patient #4 A review of the POC dated 09/25/24 to 11/23/24 showed documentation of SN to review blood sugar log and to conduct a fingerstick blood sugar if the patient has not performed it the day of the visit and report to the physician random fingerstick blood sugar 300. Documentation showed during SN visits dated 10/02/24, 10/09/24, 10/17/24, 10/23/24 and 10/28/24 the patient declined monitoring his FSBS. Documentation showed no physician communications or coordination of care notes related to patient continued to decline monitoring his FSBS and showed no changes in orders. On 10/31/24 at 9:27 a.m., Staff B stated the SN should have communicated the patient’s non-compliance to monitor the FSBS with the physician. Patient #8 A review of the POC dated 09/17/24 to 11/15/24 showed documentation of SN to monitor patient’s weight and report to the physician weight gain of 3 pounds in one day or 5 pounds in a week. Documentation showed during SN visits dated 10/23/24 the patient’s weight was 219 pounds; 10/25/24 the patient’s weight was 216 pounds and on 10/28/24 the patient’s weight was 229 pounds (13-pound increase). Documentation showed no physician communications or coordination of care notes related to the patient’s weight gain and showed no changes in orders. On 10/31/24 at 9:38 a.m., Staff B stated the SN should have communicated the patient’s 13-pound weight gain in 3 days with the physician. Patient #11 A review of the POC dated 09/06/24 to 11/04/24 showed no orders for SN to monitor patient’s weight. Documentation showed during SN visits dated 09/06/24 the patient’s weight was 206 pounds; 09/12/24 the patient’s weight was 200 pounds; and on 09/24/24 the patient’s weight was 183 pounds (23-pound unanticipated weight loss). Documentation showed no physician communications or coordination of care notes related to the patient’s continued weight loss. On 10/31/24 at 9:44 a.m., Staff B stated the SN should have communicated the patient’s 23-pound weight loss to the physician.

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 performed ordered administration of medication for one (Patients #4) of 17 patients; MSW visits were conducted as ordered for one (Patient #7) of 17 patients; PT visits were conducted as ordered for two (Patients #11 and #14) of 17 patients; CHHA visits were conducted as ordered for two (Patients #11 and #17) of 17 patients and; SN visits were conducted as ordered for three (Patients #12, 16 and #17) of 17 patients. Findings: Patient #4 A review of the POC dated 09/25/24 to 11/23/24 showed documentation of SN to administer the medication, Invega 234 milligrams intramuscular injection every month due week of 10/04/24. Documentation showed during SN visit dated 10/02/24 (week of 10/04/24) the medication was not administered. Documentation showed no physician communications or coordination of care notes related to the medication was not administered to the patient, showed no documentation of patient refusal, and showed no changes in orders. On 10/31/24 at 9:27 a.m., Staff B stated the SN should have administered the medication as ordered in the POC. Patient #7 A review of the POC dated 08/25/24 to 10/23/24 showed orders for MSW visit frequency of one to two times in 60 days. Documentation showed no MSW visits from 08/25/24 to 10/23/24. Documentation showed patient refusal of visits, no physician notifications, and no change in orders. On 10/31/24 at 9:35 a.m., Staff B stated the MSW visits for patient #7 should have been conducted as ordered on the POC. Patient #11 A review of the POC dated 09/06/24 to 11/04/24 showed no orders for PT visit frequency of two times a week for three weeks, then one time a week for one week; and CHHA visits one time a week for eight weeks. Documentation showed no PT visits on 09/15/24 and 10/10/24 due to no authorization for payment; and CHHA visit for 10/10/24 was missed due to no staff available. Documentation showed no patient refusal of visits, no physician notifications, and no change in orders. On 10/31/24 at 9:44 a.m., Staff B stated the PT and CHHA visits for patient #11 should have been conducted as ordered on the POC. Patient #12 A review of the POC dated 09/03/24 to 11/01/24 showed orders for SN to conduct assessment and monitoring of patient blood sugar every visit and report to physician FSBS 300 and to perform wound site care three time a week for nine weeks. Documentation showed SN visits conducted on 10/02/24 showed documentation of no review of blood sugar log or performance of the FSBS; and SN visit on 10/04/24 was missed due to no authorization for payment. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the blood sugar during the SN visits, no physician and no change in orders. On 10/31/24 at 9:50 a.m., Staff B stated the SN should have conducted assessment and monitoring of the patient’s blood sugar every visit and conducted SN visit frequency as ordered by the physician. Patient #14 A review of the POC dated 04/22/24 to 06/20/24 showed orders for PT evaluate and treat. Documentation showed no PT evaluation and treatment visits due to no authorization for payment. Documentation showed no patient refusal of visits, no physician notifications, and no change in orders. On 10/31/24 at 9:56 a.m., Staff B stated the PT evaluation visit for patient #14 should have been conducted as ordered on the POC. Patient #16 A review of the POC dated 05/06/24 to 07/04/24 showed orders for SN visit frequency of one time every other week for nine weeks to conduct assessment and monitoring; and instruction and teaching of the patient’s health conditions every visit and report to changes to the physician. Documentation showed a SN visit on 10/04/24 was missed due to not scheduling the nurse until paperwork is current and submitted timely. Documentation showed no patient/caregiver refusal of the SN visit, no physician notification, and no change in orders. On 10/31/24 at 10:05 a.m., Staff B stated the SN should have conducted SN visit frequency as ordered by the physician. Patient #17 A review of the POC dated 08/18/24 to 10/16/24 showed orders for SN visit frequency of one time a week for nine weeks and CHHA visit frequency of one time a week for nine weeks. Documentation showed during the week of 08/19/24 to 08/25/24 no SN visit was conducted (one visit ordered, visit was conducted); during the weeks of 09/02/24 to 09/22/24 no CHHA aide visit were conducted (three visits ordered, no visits conducted). Documentation showed no patient/caregiver refusal of SN or CHHA visits, no physician notifications, and no change in orders. On 10/31/24 at 10:08 a.m., Staff B stated the SN and CHHA should conducted visits as ordered by the physician.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative QAPI records showed no multi-disciplined skilled professional staff (PT, OT, ST or MSW in addition to SN) participation in QAPI activities for calendar year 2023 and 01/01/24 to 10/30/24. On 10/31/24 at 9:00 p.m., Staff B stated documentation showed no multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for two (Patients #7 and #11) of 17 patients. Findings: Patient #7 A review of the POC dated 08/25/24 to 10/23/24 showed orders for CHHA visit frequency of twice a week for nine weeks. A review of the clinical record showed CHHA visits completed 08/27/24, 08/29/24, 09/03/24, 09/05/24, 09/10/24, 09/12/24, 09/17/24, 09/19/24, 09/24/24 and on 09/26/24. Documentation showed supervisory visits were completed on 08/28/24, 09/10/24 and on 09/26/24 (16 days between supervisory visits). Documentation showed no patient refusal of supervisory visits, no physician notification, and no change in orders. On 10/31/24 at 9:35 a.m., Staff B stated the CHHA supervisory visits for patient #7 should have been conducted at least every 14 days. Patient #11 A review of the POC dated 09/06/24 to 11/04/24 showed orders for CHHA visit frequency of one a week for eight weeks. A review of the clinical record showed CHHA visits completed 09/12/24, 09/19/24, 10/03/24, 10/10/24 and on 10/17/24. Documentation showed supervisory visits were completed on 09/19/24, 10/01/24 and on 10/18/24 (17 days between supervisory visits). Documentation showed no patient refusal of supervisory visits, no physician notification, and no change in orders. On 10/31/24 at 9:44 a.m., Staff B stated the CHHA supervisory visits for patient #11 should have been conducted at least every 14 days.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 11/03/21 to 11/05/21.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 patients and all employees. 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 November 05, 2021.On 11/05/21 at 11:50 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 November 05, 2021.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 11/03/21 to 11/05/21.An entrance conference was conducted with Staff A, B, C and D. The survey process was explained. Questions were answered.Staff A and B were identified as the contact persons for administrative issues and Staff B and E were identified as the contact persons for clinical issues.Findings were discussed during an informal exit conference with Staff A, B, C and F.Deficiencies were cited as a result of the re-certification survey:GLOSSARY:QAPI Quality Assessment and Performance Improvement

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. the physician was notified of finger stick blood sugar levels outside the ordered parameters for one (Patient #2) of 17 patients; 2. weights were obtained as ordered for one (Patient #3) of 17 patients; 3. the physician was notified of weights outside of ordered parameters for two (Patient #3 and 4) of 17 patients; 4. assessment of wound was performed as ordered for one (Patient #8) of 17 patients and 5. the physician was notified of pain levels outside of ordered parameters for one (Patient #9) of 17 patients. 1. Patient #2 A review of the plan of care dated 07/18/21 to 09/15/21 showed orders to notify the physician of a fasting or random blood sugar greater than 300. A skilled nurse assessment dated 09/03/21 documented a blood sugar of 345 with no documented physician notification. 2. Patient #3 A review of the plan of care dated 10/08/21 to 12/06/21 showed orders for the skilled nurse to assess and monitor weights every visit or every week and documented a skilled nurse frequency of one visit per week for nine weeks. A review of the electronic medical record showed the following: A skilled nurse assessment dated 10/14/21 showed no documented weight. A skilled nurse assessment dated 10/21/21 showed no documented weight. A skilled nurse assessment dated 10/28/21 showed no documented weight. 3. Patient #4 A review of the plan of care dated 07/30/21 to 09/27/21 showed orders for the physician to be notified of weight greater than 274 pounds. A skilled nurse assessment dated 09/16/21 documented a weight of 306 pounds with no physician notification and skilled nurse assessment dated 09/23/21 documented a weight of 305 pounds with no physician notification. 4. Patient #8 A review of the plan of care dated 08/27/21 to 10/25/21 showed orders for the skilled nurse to assess and evaluate wound at each dressing change and documented a skilled nurse frequency of one visit per week for one week and two visits per week for two weeks. A review of the electronic medical record showed the following: A skilled nurse assessment dated 08/27/21 during the week of 08/27/21 to 08/29/21 (one of one assessment) documented no wound measurements. A skilled nurse assessment dated 08/31/21 during the week of 08/30/21 to 09/05/21 (one of one assessments) documented no wound measurements. A skilled nurse assessment dated 09/07/21 and 09/10/21 during the week of 09/06/21 to 09/12/21 (two of two assessments) documented no wound measurements. A skilled nurse assessment dated 09/14/21 during the week of 09/13/21 to 09/19/21 (one of one assessments) documented no wound measurements. 5. Patient 9 A review of the plan of care dated 08/26/21 to 10/24/21 showed orders to notify the physician of pain levels greater than 7 on the classic 1-10 pain scale. A review of the electronic medical record showed the following: A skilled nurse assessment dated 09/01/21 documented a pain level of 8 and patient statement of the pain medication being ineffective with no physician notification. A skilled nurse assessment dated 09/07/21 documented a pain level of 8 and patient statement of the pain medication being ineffective with no physician notification. A skilled nurse assessment dated 09/21/21 documented a pain level of 8 and patient statement of the pain medication being ineffective with no physician notification. A skilled nurse assessment dated 09/28/21 documented a pain level of 8 and patient statement of the pain medication being ineffective with no physician notification. A skilled nurse assessment dated 10/05/21 documented a pain level of 8 and patient statement of the pain medication being ineffective with no physician notification. A skilled nurse assessment dated 10/12/21 documented a pain level of 8 and patient statement of the pain medication being ineffective with no physician notification. On 11/05/21 at 9:25 am, Staff E stated: 1) the physician should have been notified of the finger stick blood sugar outside the ordered parameters for Patient #2; 2) weights should have been obtained as ordered for Patient #3; 3) the physician should have been notified of weights outside of the ordered parameters for Patient #4; 4) wound measurements should have been obtained for Patient #8 and 5) the physician should have been notified of pain levels outside the ordered parameters for Patient #9.

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 review and interview, the agency failed to ensure physician orders were obtained for skilled nurse visits for one (Patient #2) of seventeen patients. A review of the plan of care dated 07/05/21 to 09/02/21 showed a skilled nurse frequency of one visit per week for four weeks. A physician order dated 07/26/21 showed a skilled nurse frequency of two visits per week for three weeks. A physician's order dated 08/16/21 showed a skilled nurse frequency of two visits per week for three weeks. A review of the electronic medical record showed skilled nurse visits on 09/08/21 and 09/10/21 during the week of 09/06/21 to 09/12/21 (two skilled nurse visits) and a skilled nurse visit on 09/15/21 during the week of 09/13/21 to 09/15/21 (one skilled nurse visit). Documentation showed no additional visits ordered for the weeks of 09/06/21 to 09/12/21 or 09/13/21-09 On 10/06/21 at 11:30 am, Staff F stated there were no orders for skilled nurse visits for the weeks of 09/06/21 to 09/12/21 and the time period of 09/13/21 to 09/15/21.

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 review and evaluation of a patient centered QAPI Program for all patients and employees. FindingsA review of administrative records showed no ongoing patient centered QAPI program and no QAPI data was collected, monitored or evaluated by the agency for July 01, 2020 through November 05, 2021. On 11/05/21 at 10:30 a.m., Staff E stated there was no documentation of review and evaluation of the QAPI program for 2019, 2020 and July 1, 2020 through November 05, 2021.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals (Registered Nurse and Physical Therapist) accurately documented clinical diagnosis and/or the reason for visits by the clinician for two (Patients #1 and 3) of seventeen patients. Patient #1 A review of the plan of care dated 07/27/21 to 09/24/21 showed a primary diagnosis of a stage IV pressure ulcer of the sacrum and documented a skilled nurse frequency of two visits per week for one week and then three visits per week for eight weeks. A review of the electronic medical record showed the following: A skilled nurse assessment dated 07/28/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 07/30/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/02/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/04/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/06/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/09/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).A skilled nurse assessment dated 08/12/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).A skilled nurse assessment dated 08/16/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/18/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/20/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/23/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/25/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/27/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 08/30/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 09/01/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 09/03/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).A skilled nurse assessment dated 09/06/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 09/08/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).A skilled nurse assessment dated 09/13/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).A skilled nurse assessment dated 09/15/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).A skilled nurse assessment dated 09/17/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).A skilled nurse assessment dated 09/20/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 09/22/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer). A skilled nurse assessment dated 09/24/21 documented a sacral stage II decubitus ulcer (no documentation of a stage IV decubitus ulcer).Patient #3 A review of the plan of care dated 10/08/21 to 12/06/21 showed a primary diagnosis of hypertensive heart with failure and documented a physical therapy frequency to evaluate and treat the week of 10/11/21. An initial physical therapy frequency was documented for two times per week. A review of Physical Therapy visit notes dated 10/12/21, 10/15/21, 10/19/21, 10/22/21, 10/27/21 and 10/28/21 documented hypertension as the reason for the physical therapy visit with no documentation of the heart failure. On 11/05/21 at 9:45 am., Staff E stated the skilled nurse assessments failed to accurately document the stage of the sacral pressure ulcer for Patient #1 and the physical therapy assessments failed to document the correct diagnosis for Patient #3.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of missed visits for three (Patients #1, 5 and 8) of 17 patients. Patient #1 A review of the plan of care dated 07/27/21 to 09/24/21 showed a skilled nurse frequency of two visits per week for on week and three visits per week for eight weeks. A review of the electronic medical record showed a missed visit note dated 08/13/21 during the week of 08/09/21 to 09/15/21 (two completed skilled nurse visits) with no documentation of physician notification and a missed visit note dated 09/10/21 during the week of 09/06/21 to 09/12/21 (two completed skilled nurse visits) with no documentation of physician notification. Patient #5 A review of the plan of care dated 08/09/21 to 10/07/21 showed a skilled nurse frequency of one visit per week for nine weeks. A review of the electronic medical record showed a missed visit note dated 09/03/21 during the week of 08/30/21 to 09/05/21 (no completed skilled nurse visits) with no documentation of physician notification and a missed visit note dated 10/01/21 during the week of 09/27/21 to 10/03/21 (no completed skilled nurse visits) with no physician notification. Patient #8 A review of the plan of care dated 08/27/21 to 10/25/21 showed a skilled nurse frequency of one visit per week for one week and two visits per week for eight weeks. A review of the electronic medical record showed a missed visit note on 09/03/21 during the week of 08/30/21 to 09/05/21 (one completed skilled nurse visit) with no documentation of physician notification and a missed visit note dated 09/17/21 during the week of 09/13/21 to 09/19/21 (one completed skilled nurse visit) with no physician notification. On 11/05/21 at 10:27 a.m., Staff E stated the physician should have been notified of the missed visits for patients #1, 5 and 8.