Every finding on record at Prairie View Home Health, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 01/14/26 to 01/15/26. 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: Findings: A review of emergency preparedness records showed no community-based risk assessment for the agency, its patient population, or its employees. On 01/15/26 at 11:05 a.m., Staff A stated the agency did not have a community based All Hazards Risk Assessment.

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 calendar year 2024 for all patients and employees. Findings: A review of emergency preparedness records showed no table-top exercises, drills, community drills or plan activation events for calendar year 2024. On 01/15/26 at 11:05 a.m., Staff A stated the agency had no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for 2024.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 01/14/26 to 01/15/26. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary notice EP Emergency Preparedness HHA Home Health Agency HHCOC home health change of care PT physical therapy POC Plan of Care QAPI quality assessment performance improvement 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: Findings: Patient #9 A review of the clinical record showed no advance notice of discharge or home health change of care notice was provided to the patient prior to discharge from the agency on 08/29/25 for a change in payor source. On 01/15/26 at 12:37 p.m., Staff B stated the patient did not receive an advance notice of discharge prior to the discharge from agency services.

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 an initial evaluation/SOC assessment was conducted within 48 hours of referral for three (Patients #1, 2 and #3) of 11 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 12/23/25 and the initial evaluation/SOC assessment occurred on 12/26/25 (three days after the referral). The clinical record showed no patient refusal of the initial evaluation/SOC assessment, no physician notification of a delay in initial evaluation/SOC assessment and no change in orders. On 01/15/26 at 12:00 p.m., Staff A stated the patient should have started on services within two days of the referral. Patient #2 A review of the clinical record showed the agency received referral information on 11/12/25 and the initial evaluation/SOC assessment occurred on 11/18/25 (six days after the referral). The clinical record showed no patient refusal of the initial evaluation/SOC assessment, no physician notification of a delay in initial evaluation/SOC assessment and no change in orders. On 01/15/26 at 12:05 p.m., Staff A stated the patient should have started on services within two days of the referral. Patient #3 A review of the clinical record showed the agency received referral information on 10/23/25 and the initial evaluation/SOC assessment occurred on 10/29/25 (six days after the referral). The clinical record showed no patient refusal of the initial evaluation/SOC assessment, no physician notification of a delay in initial evaluation/SOC assessment and no change in orders. On 01/15/26 at 12:10 p.m., Staff A stated the patient should have started on services within two days of the referral.

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 patient POC included a last conducted or next date a skilled intervention was due for one (Patient #11) of 11 patients. Findings: Patient #11 A review of a POC dated 11/11/25 to 01/09/26 showed orders for SN to conduct indwelling Foley catheter change every month. The POC showed no last conducted or next date that the skilled intervention was due. On 01/15/26 at 12:46 p.m., Staff A stated the POC did not document the date the catheter change occurred or when the skilled intervention was due.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders for physical therapy interventions and goals were a part of the patient’s plan of care for two (Patients #5 and #8) of 11 patients. Findings: Patient #5 A review of the POC dated 12/19/25 to 02/16/26 showed orders for physical therapy to evaluate with a frequency of one time a week for one week. The clinical record showed a written physical therapy evaluation dated 12/20/25 signed by the physician on 12/22/25. The clinical record showed no update to the POC and no transcribed physician’s order with physical therapy frequency and duration, interventions or goals. On 01/15/26 at 12:19 p.m., Staff A stated the POC was not updated after the PT evaluation. Patient #8 A review of the POC dated 08/16/25 to 10/14/25 showed orders for physical therapy to evaluate with a frequency of one time a week for one week. The clinical record showed a written physical therapy evaluation dated 08/18/25. The clinical record showed no update to the POC and no transcribed physician’s order with physical therapy interventions or goals. On 01/15/26 at 12:30 p.m., Staff A stated the POC was not updated after the PT evaluation.

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 with the medical provider for one (Patient #6) of 11 patients. Findings: Patient #6 A review of the POC dated 11/19/25 to 01/17/26 showed orders for SN frequency and duration of once every other week for nine weeks to conduct indwelling Foley catheter changes every two weeks. SN visit note dated 11/21/25 stated the patient refused the Foley catheter change and requested it be done at the next SN visit (two weeks later). The clinical record showed no physician notification the patient requested the indwelling Foley catheter to be changed in four weeks instead of two weeks and showed no changes in orders. A review of a SN visit note dated 12/03/25 showed the collection of urine for urinalysis. The clinical record showed the results were auto faxed to the physician’s office on 12/08/25 with no follow-up communications. A physician’s order dated 12/19/25 was received for the patient to take oral antibiotics to treat a urinary tract infection based on the urinalysis results from 12/03/25. On 01/15/26 at 12:23 p.m., Staff A stated: The nurse did not communicate the patient’s request to change the catheter in four weeks instead of two weeks to the physician.The nurse should have followed up with the physician after the urinalysis results were auto faxed to the physician’s office.

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: Findings: A review of QAPI and Infection Control Program records showed no infection control program surveillance monitoring and reporting as a part of QAPI program for calendar years 2024 and 2025. On 01/15/26 at 11:30 a.m., Staff A stated the infection control monitoring was not included in the QAPI program.

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 QAPI records showed no multi-disciplined skilled professional staff (PT, OT, ST or MSW in addition to SN) participation in QAPI activities in calendar year 2024 and 01/01/25 to 06/30/25. On 01/15/26 at 11:30 a.m., Staff A stated QAPI activities did not include multi-disciplined staff participation.

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 transfer/discharge summaries were provided to receiving service providers for two (Patients #4 and #8) of 11 patients. Findings: Patient #4 A review of a SN communication note dated 11/26/25 showed the patient was transferred to inpatient facility after a fall. A transfer summary dated 11/30/25 was auto faxed to the physician on 12/01/25 (five days later). The clinical record showed no communications or transfer summary was provided to the inpatient provider. On 01/15/26 at 12:15 p.m., Staff B stated the transfer summary was not provided to the inpatient provider. Patient #8 A review of a SN communication note dated 09/24/25 showed the patient was transferred to inpatient facility for respiratory symptoms and oxygen saturation rates of 74-83%. A transfer with discharge summary dated 09/24/25 was auto faxed to the physician on 10/01/25 (six days later). The clinical record showed no communications or transfer with discharge summary was provided to the inpatient provider. On 01/15/26 at 12:30 p.m., Staff B stated the transfer with discharge summary was not provided to the inpatient provider.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/17/23 to 01/18/23. 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 in conjunction with a complaint investigation for complaint #OK00056903 at the agency on 01/17/23 to 01/18/23. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. 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. No deficiencies were cited related to the complaint. Glossary: HHA Home Health Agency PIP Performance Improvement Project POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

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 one (Patient #6) of seven patients. Findings: Patient #6 A review of clinical documentation showed the patient was discharged from the agency after a change in an insurance provider on 11/29/22 and showed no documentation of an advance notice of discharge prior to discharge from the agency. On 01/18/23 at 11:15 a.m., Staff A stated Patient #6 received no advance notice of discharge prior to their discharge from agency services.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC included: 1. Vitamin B12 intramuscular injection treatment intervention due date for one (Patient #1) of seven and; 2. Pain reporting parameters for physician notification for one (Patient #3) of seven. Findings: Patient #1 A review of the POC dated 12/11/22 to 2/08/23 showed orders for SN to administer monthly Vitamin B12 intramuscular injection. POC documentation showed no treatment intervention due date or last date the treatment intervention was conducted. Documentation showed no physician notifications and no change in orders. Patient #3 A review of the POC dated 12/20/22 to 2/17/23 showed orders for SN to conduct assessment, monitoring and instruction of patient pain every visit. POC documentation showed no physician notification pain reporting parameters. Documentation showed no physician notifications and no change in orders. On 01/18/23 at 11:15 p.m., Staff A stated POCs for: 1. Patients #1 should have included treatment intervention due dates for the certification period and; 2. Patient #3 should have included pain reporting parameters for physician notification.

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. Findings: Review of administrative records of a patient centered QAPI program for the agency showed no quality indicator data was utilized in the agency's QAPI Program for 03/01/20 to 12/31/20 and calendar years 2021 and 2022. Additional administrative records were requested. No additional records were provided. On 01/18/23 at 10:00 a.m., Staff A stated there was no documentation which showed the utilization of quality indicator data in the conduction of QAPI Program activities for 03/01/20 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. Findings: Administrative records were reviewed and showed no conduction of patient centered QAPI Program activities to improve the care, services, and operations of the agency for 03/01/20 to 12/31/20 and calendar years 2021 and 2022. Documentation showed no data, no data collection sources, no data analysis, no identification of issues or problems and showed no agency interventions or subsequent follow up of interventions. Additional administrative records were requested. No additional records were provided. On 01/18/23 at 10:00 a.m., Staff A stated there was no documentation which showed the conduction of a patient centered QAPI Program activities for 03/01/20 to 12/31/20 and calendar years 2021 and 2022 that showed data, data collection sources, data analysis, identification of issues or problems by the agency or showed agency interventions and subsequent follow up of interventions.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: Administrative records of multi-disciplined skilled professional staff participation in the agency’s QAPI program from 03/01/20 to 12/31/20 and calendar years 2021 and 2022 was requested. No documentation was provided. On 01/18/23 at 10:00 a.m., Staff A stated there was no documentation which showed evidence of ongoing QAPI program activities with multi-discipline professional staff participation to improve the care, services, and operations of the agency from 03/01/20 to 12/31/20 and calendar years 2021 and 2022.

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 to a receiving service provider for one (Patients #7) of seven patients. Findings: Patient #7 A review of the clinical record documented transfer from the agency on 12/04/22 to inpatient hospital provider services with subsequent discharge to hospice provider services. Documentation showed no transfer/discharge summary was provided to the inpatient hospital service provider. On 01/18/23 at 11:30 a.m., Staff A stated no transfer/discharge summary was sent to the receiving service provider for patient #7.