Every finding on record at Restore Home Healthcare of Oklahoma, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/16/25 - 04/18/25. 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 04/16/25 - 04/18/25 in conjunction with a Medicare complaint surveys (#101753 and #111109). An entrance conference was conducted with the Staff A, Staff B, Staff C and Staff D. The survey process was explained. Questions were answered. The Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, Staff B and Staff C. Deficiencies were cited as a result of the Medicare re-certification survey. No deficiencies were cited as a result of complaint surveys (#101753 and #111109). Glossary: SN Skilled Nurse SOC Start of Care POC Plan of Care

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 conduct a review of all medications the patient was currently using to identify adverse effects and drug reactions, side effects, and duplicate drug therapy for four (#1, #4, #5 and #7) of seventeen (#1- #17) records reviewed. Pt #1 During a home visit on 04/16/25, the current client medication profile showed Humalog U-100 Insulin to be taken 1 Unit as directed subcutaneous. On 04/16/25 at 1:30 PM, Pt#1 stated he had Type II Diabetes Mellitus, takes Metformin but does not take Insulin. Pt #4 During a home visit on 04/17/25, the current client medication profile included Humalog Kwikpen U-100 Insulin to be taken 1 ml 3 times daily subcutaneous. No sliding scale instructions were included on the client medication profile. Further review of the client medication report failed to include Torsemide found in the home and prescribed on 03/10/25. Documentation showed the medication profile was last reviewed by SN #1 on 02/25/25. On 04/17/25 at 08:30 AM, Pt#4 stated they had Type II Diabetes Mellitus and takes Insulin on a sliding scale, and takes Furosemide for her fluid and showed a bottle with prescription dated August 2024. Pt #5 During a home visit on 04/17/25 at 11:30 AM, the current Client Medication Profile included Torsemide 20 mg 1 tablet daily. Documentation showed no use of Ozempic and was last reviewed by SN #22 on 04/02/25. On 04/17/25 at 11:30 AM, Pt#5 stated Torsemide was increased to 80 mg after their recent hospitalization of 3/31/25. Pt #5 also stated they lost weight taking Ozempic for the past 2 months. Pt #7 Review of the current Client Medication Profile on 04/17/25 showed multiple duplicate medications and no evidence a SN conducted a drug regimen review since the SOC review conducted by SN1 on 04/02/25. During an interview on 04/18/25 at 10:15 AM, Staff A explained the agency process regarding medication reports and stated the SN staff failed to review medications to ensure current and accurate medication reports for Pts #1, #4, #5 and #7.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to promptly alert the physician of a change in the patient's condition for two (#5 and #12) of seventeen (#1- #17) records reviewed. Pt #5 A review of the POC showed a recertification period 03/20/25 - 05/18/25 and a diagnosis of Congestive Heart Failure. SN Visit weight documentation on 4/2/25 showed 303 pounds. A SN visit on 4/04/25 showed 308 pounds, a five- pound weight gain in two days. Further review failed to provide evidence the physician was notified of the weight- gain. No weight parameters were identified on the POC. Pt #12 A review of the POC for Patient #12 showed an initial certification period of 02/22/25 - 04/22/25 and a diagnosis of Congestive Heart Failure. A SN Visit note dated 3/4/25 showed a weight of 123.6 pounds and a SN Visit note dated 3/20/25 showed 132.2 pounds, a nine-pound weight gain in two weeks. Further review failed to provide evidence the physician was notified of the weight-gain. No weight parameters were identified on the POC. During an interview on 04/18/25 at 10:15 AM, Staff A stated the agency failed to notify the physician of significant weight changes for Pts #5 and #12.

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 review and interview, the agency failed to provide a completed transfer summary to the facility within 2 business days of becoming aware of an unplanned transfer for one (#16) of five (#13- #17) discharged records reviewed. A review of the POC for Patient #16 for recertification period 01/04/25 - 03/04/25 showed a transfer to a short-term general hospital on 01/18/25 and a discharge date of 02/11/25. Further review failed to provide evidence a transfer summary was sent to the facility as required. During an interview on 04/18/25 at 10:15 AM, Staff A stated the agency failed to send a completed transfer summary to the facility within 2 business days of becoming aware of an unplanned transfer for Pt #16.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/16/22 to 05/17/22. 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), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 315 patients and all employees. Findings: A review of administrative records showed no documentation of a community-based risk assessment which addressed the agency, its patient population, or its employees. This failed practice had the potential to cause unnecessary delays during actual emergencies for all patients and agency staff. On 05/17/22 at 12:00 p.m., Staff A stated the agency had no emergency preparedness community-based risk assessment.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included updated staff contact information for 315 patients and all employees . Findings: A review of administrative records showed the Emergency Preparedness Communication Plan included staff contact information for former staff members who no longer worked for the agency. On 05/17/22 at 12:00 p.m., Staff A stated current contact information for active staff members was not a part of an Emergency Preparedness Communication Plan for the agency.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included contact information for emergency management of agency resources for the agency and affecting 315 patients and all employees. Findings: A review of administrative records showed no contact information for emergency management of agency resources for the agency. On 05/17/22 at 12:00 p.m., Staff A stated the Emergency Preparedness Communication Plan did not include required contact information for the emergency management of agency resources for the agency.

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), §485.625(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, 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 an emergency preparedness disaster table-top exercise, drill, participation in a community-based drill, or declaration was conducted for calendar year 2021 and 01/01/22 through 05/17/22 for 315 patients and employees. Findings: A review of administrative records showed no agency disaster table-top exercise, drill or participation in a community-based drill, or declaration for calendar year 2021 and 01/01/22 through 05/17/22. On 05/17/22 at 12:00 p.m., Staff A stated the agency had no documentation of an emergency preparedness disaster table-top exercise, drill or participation in a community-based drill, or declaration for calendar year 2021 and 01/01/22 through 05/17/22.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 05/16/22 through 05/17/22. An entrance conference was conducted with Staff A and Staff B. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B and Staff C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: OT Occupational Therapy PT Physical Therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN Skilled Nurse SNF Skilled Nursing Facility

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 notice of discharge was provided prior to being discharged from the agency for one (Patient #13) of 17 patients. Findings: Patient #13 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 12/15/21 for non-compliance. On 05/17/22 at 4:05 p.m., Staff B stated there was no: advance notice of discharge in the clinical record for Patient #13 and;Patient #13 should have received an advanced notice of discharge for non-compliance prior to being discharged from the agency.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient education on potential health outcomes related to refusal of PT visits for one (Patient #13) of 17 patients. Findings: Patient #13 A review of a POC for 11/30/21 to 01/28/22 showed a PT visit frequency of two times a week for one week, then three times a week for two weeks. A review of visit notes showed missed PT visits on 12/02/21, 12/06/21, 12/08/21 12/09/21, 12/13/21 and 12/15/21. Documentation showed the patient was discharged from agency services on 12/16/21 with no communication or education attempts to the patient for potential health outcomes related to refusal of PT visits prior to the discharge date of 12/15/21 for non-compliance. On 05/17/22 at 4:05 p.m., Staff B stated there was no documentation of attempts to educate the patient of potential health outcomes related to refusal of PT visits prior to discharge from the agency on 12/15/21 for non-compliance.

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 reviewed and updated with dose instructions for an ordered medication for one (Patient #14) of 17 patients. Findings: Patient #14 A review of a POC dated 11/30/21 to 01/28/22 showed an order for Lasix 40 mg, take 3 tablets by mouth on Monday, Wednesday, Friday and 2 tablets on Sunday, Tuesday, Thursday and Saturday; and Spironolactone 25 mg one tablet Monday, Wednesday and Friday. A patient note/communication dated 12/08/21 stated SN received telephone call from the doctor’s office to increase oral diuretic to two pills a day until swelling of lower extremities subsided. Documentation showed no identification of the specific diuretic medication and no indication of how long the patient was to continue the change in the medication dosage. The medication profile was not updated to reflect the ordered change in the medication regimen. On 05/17/22 at 4:07 p.m., Staff B stated the SN should have: documented which diuretic medication dose was to be altered and for how long the patient was to change the dose; and the medication profile should have been updated to reflect the change in the medication regimen.

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 the individualized patient POC included: Recurring urinary catheter change due dates documented for one (Patient #10) of 17 patients and;Recurring intramuscular injection treatment due dates documented for one (Patient #10) of 17 patients. Findings: Patient #10 A review of the plan of care dated 04/28/22 to 06/26/22 documented a principal diagnosis of quadriplegia. POC orders instructed: SN to change indwelling Foley catheter every month. POC documentation showed no treatment date the indwelling Foley catheter change was due and;SN to perform Testosterone intramuscular injections every 2 weeks. POC documentation showed no treatment date the intramuscular injections were due. On 05/17/22 at 4:00 p.m., Staff B stated: Recurring urinary catheter change due dates should have been documented for in the POC and;Intramuscular injection treatment due dates should have been documented in the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record reviews and interview the agency failed to ensure: SN performed wound care as ordered by the physician for one (Patient #3) of 17 patients and;SN visits were conducted as ordered by the physician for one (Patient #5) of 17 patients. Findings: Patient #3 A review of the plan of care dated 04/04/22 to 06/02/22 showed orders for SN visit frequencies two times a week for three weeks, then one time a week for six weeks to perform wound care to pressure ulcer of the right buttock as follows: Cleanse with sterile normal saline and apply Calmoseptine (a barrier cream ointment). Clinical documentation showed SN visits were conducted on 04/08/22, 04/13/22, 04/15/22, 04/20/22, 04/22/22, 04/27/22, 05/04/22 and on 05/11/22. Documentation showed wound care performed every visit included the use of Mepilex dressing materials (not ordered by the physician). Documentation showed no physician notification of use of the dressing materials and no change in orders. Patient #5 A review of the clinical record showed a physician order dated 04/04/22 documented SN to perform wound care two time a week for eight weeks, then one time a week for one week. Clinical documentation showed during the week of 04/10/22 through 04/16/22 SN visits were conducted on 04/11/22, 04/13/22 and on 04/15/22 (two SN visits were ordered; three SN visits were conducted.) Documentation showed no physician notification additional SN visit was needed and no change in orders. On 05/17/22 at 3:30 p.m., Staff B stated: Wound care performed for Patient #3 should not have included the use of the dressing materials and;SN visit frequency for Patient #5 should have been conducted as ordered by the physician.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure evidence of a patient centered QAPI Program for 315 patients and all employees. Findings: A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency for 3rd quarter calendar year 2020 and calendar year 2021. On 05/17/22 at 12:00 p.m., Staff A stated there was no documentation which showed a QAPI program for 3rd quarter calendar year 2020 and calendar year 2021.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 315 patients and employees. Findings: A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for 3rd quarter calendar year 2020 and calendar year 2021. On 05/17/22 at 12:00 p.m., Staff A stated: 1. They had no analysis of data collected available that showed improved quality of patient care for 3rd quarter calendar year 2020 and calendar year 2021 and; 2. Program improvement data was not available for review for 3rd quarter calendar year 2020 and calendar year 2021.

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 ensure conduction of patient centered QAPI Program activities for 315 patients and employees. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for 3rd quarter calendar year 2020 and calendar year 2021. On 05/17/22 at 12:00 p.m., Staff A stated they had no QAPI documentation which showed QAPI program activities for3 rd quarter calendar year 2020 and calendar year 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 315 patients and employees. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs in calendar year's 2020 and 2021. On 05/17/22 at 12:00 p.m., Staff A stated the agency had no documentation which showed PIP activities calendar year's 2020 and 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 was included in QAPI activities for 315 patients and employees. Findings: A review of QAPI administrative records showed no documentation of infection control surveillance data for calendar year's 2020 and 2021. On 05/17/22 at 12:00 p.m., Staff A stated infection surveillance activities were not reported through the agency's QAPI program for calendar year's 2020 and 2021.

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 the following services were provided as ordered on the POC for: 1. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for one (Patient #1) of 17 patients; 2. PT evaluations were conducted for two (Patient #2 and Patient #3) of 17 patients; 3. OT evaluations were conducted for three (Patients #2, 7 and Patient #8) of 17 patients and; 4. SN performed wound care as ordered for one (Patient #5) of 17 patients. Findings: Patient #1 A review of the POC dated 03/30/22 to 05/28/22 showed orders for SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight of less than 169 pounds. Documentation showed no patient weight assessment was conducted during SN visits on 04/01/22, 04/11/22 and on 04/15/22; and during the SN visits conducted on 05/04/22 the patient’s weight was documented as 158 pounds, on 05/11/22 157 pounds, and on 05/13/22 157 pounds. Documentation showed no patient/caregiver refusal of patient weight assessment, no physician notification of the weight loss and no change in orders. Patient #2 A review of the POC dated 04/28/22 to 06/26/22 showed a PT frequency of one week one, effective week of 04/28/22 and an OT frequency of one week one, effective week of 04/28/22. A review of clinical record showed the PT evaluation was conducted 05/05/22 (5 days past the ordered evaluation date range) and the OT evaluation was conducted on 05/06/22 (6 days past the ordered evaluation date range). Documentation showed no attempts to complete the PT and OT evaluations within the ordered date range, no physician notification of refused or missed visit attempts and no change in orders. Patient #3 A review of the POC dated 04/04/22 to 06/02/22 showed a PT frequency of one week one, effective week of 04/04/22. A review of clinical record showed no PT evaluation was conducted. Documentation showed no attempts to complete the PT evaluation, no physician notification of refused or missed visit attempts and no change in orders. Patient #5 A review of the POC dated 04/01/22 to 05/30/22 showed a SN visit frequency of three times a week for eight weeks, then one time a week for one week and for SN to perform wound care every visit. POC documentation showed wound care as: Cleanse with sterile normal saline, apply barrier cream, cover with calcium alginate and cover with a foam dressing material. A review of SN visits conducted on 04/07/22, 04/11/22, 04/13/22 and on 04/19/22 show no calcium alginate was applied to the wound sites during the provision of wound care; and SN visits conducted on 04/15/22 and on 04/29/22 show no wound care was provided during the SN visits. Documentation showed no patient/caregiver refusal of the dressing materials or the provision of wound care, no physician notification and no change in orders. Patient #7 A review of the POC dated 04/09/22 to 06/07/22 showed a physician’s order dated 04/13/22 for OT evaluation with a frequency of one week one, effective week of 04/13/22. A review of the clinical record showed the OT evaluation was conducted 04/23/22 (7 days past the ordered evaluation date range). Documentation showed no attempts to complete the OT evaluation within the ordered date range, no physician notification of refused or missed visit attempts and no change in orders. Patient #8 A review of the POC dated 04/03/22 to 06/01/22 showed a physician’s order dated 05/03/22 for OT evaluation with a frequency of one week one, effective week of 05/03/22. A review of the clinical record showed the OT evaluation was conducted 05/11/22 (4 days past the ordered evaluation date range). Documentation showed no attempts to complete the OT evaluation within the ordered date range, no physician notification of refused or missed visit attempts and no change in orders. On 05/17/22 at 3:30 p.m., Staff B stated: SN should have conducted patient weight assessments for Patient #1 every SN visit and notified the physician of patient weight’s less than 169 pounds but did not;PT evaluations for Patient #2 and Patient #3 should have been completed within the ordered date ranges but were not;OT evaluations for Patient #2, 7 and Patient #8 should have been completed within the ordered date ranges but were not and;Wound care for Patient #5 should have been conducted every SN visit using wound care materials ordered by the physician but was not.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program for calendar year 2021; 2. An operating budget and allocation of resources activities for calendar years 2020 and 2021; and 3. An agency program evaluation for calendar years 2020 and 2021 for 315 patients and staff. Findings: A review of administrative records showed no governing body oversite of an ongoing patient centered QAPI program for calendar year 2021, no operating budget and allocation of resource activities for calendar year's 2020 and 2021; and no agency program evaluation for calendar years 2020 and 2021. On 05/17/22 at 12:30 p.m., Staff A stated there was no documentation available which showed governing body oversight for the agency for: 1. A patient centered QAPI Program for calendar year 2021; 2. An operating budget and allocation of resources activities for calendar years 2020 and 2021; and 3. An agency program evaluation for calendar years 2020 and 2021.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of an administrator and alternate administrator for the agency for all patients and staff. Findings: A review of administrative records for calendar years 2020, 2021 and for 01/01/22 through 05/17/22 showed no appointment of the administrator or alternate administrator by the agency's governing body. On 05/17/22 at 1:30 p.m., Staff A stated the governing body minutes for calendar years 2020, 2021 and for 01/01/22 through 05/17/22 were provided in their entirety and did not document appointment of the administrator or alternate administrator.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure a clinical manager was available during all operating hours for 315 patients and all employees. Findings: On 05/16/22 at 11:30 a.m., an attempt was made by the surveyor to enter the agency for survey purposes. The surveyor observed the agency door to be locked. There was no answer to multiple knocks on the door and there were no agency personnel present on site. The surveyor observed no notice posted on the door or window that the agency was temporarily closed during designated operating hours. At 11:45 a.m., the surveyor telephoned the number posted on the agency door. A representative of the agency answered the telephone call and stated they were at the Broken Arrow branch and did not know why personnel were not answering the telephone at the (parent) agency. The surveyor was placed on hold until the administrator for the agency answered the telephone call. The administrator was informed the surveyor had arrived at the agency to survey the agency and its branch office locations. The administrator of the agency stated: 1. she did not know why there were no personnel onsite at the agency; 2. she was unable to reach the agency personnel; 3. her designated office location was at the Broken Arrow branch of the agency; 4. a clinical manager should have been available; 5. she would leave from the Broken Arrow branch to arrive at the parent agency location at first opportunity. A 12:12 p.m. an agency staff member arrived at the parent agency and unlocked the door. The staff member identified herself as a Licensed Practical Nurse for the agency. She stated the administrator was on her way and that she was not able to conduct an entrance conference for the survey. At 12:25 p.m., an agency staff member arrived at the parent agency, identified herself as an RN Clinical manager and the alternate administrator for the agency. The RN Clinical manager stated the administrator for the agency was on her way and that the entrance conference for the survey would need to wait for the administrator’s arrival. At 12:35 p.m., the administrator for the agency arrived at the parent agency. The entrance conference for the survey was conducted, survey related information was requested. The administrator stated the agency should have had personnel present on-site during the designated office hours for the agency but did not.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an administrator or alternate administrator was available during operating hours for 315 patients and all employees. Findings: On 05/16/22 at 11:30 a.m., an attempt was made by the surveyor to enter the agency for survey purposes. The surveyor observed the agency door was locked, there was no answer to multiple knocks on the door and there were no agency personnel present on site. The surveyor observed no notice posted on the door or window that the agency was temporarily closed during designated operating hours. At 11:45 a.m., the surveyor phoned the agency. A telephone representative answered the telephone call and stated they were at the Broken Arrow branch and did not know why personnel were not answering the telephone at the agency location (parent). The surveyor was placed on hold until the administrator for the agency answered the telephone call. The administrator was informed the surveyor had arrived at the agency to survey the agency and its branch office locations. The administrator of the agency stated: 1. she did not know why there were no personnel onsite at the agency; 2. she was unable to reach the agency personnel by telephone; 3. her designated office was at the Broken Arrow branch; 4. she would leave from the Broken Arrow branch to arrive at the Muskogee agency location at first opportunity. At 12:35 p.m., the administrator for the agency arrived at the agency. The entrance conference for the survey was conducted, survey related information was requested. The administrator stated neither the administrator, alternate administrator, clinincal manager or designee was immediatly availble upon surveyors arrival or to provide requested information

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided for six (Patients #5, 13, 14, 15, 16 and #17) of 17 patients. Findings: Patient #5 A review of the clinical record documented transfer from the agency on 05/02/22 to in-patient provider services. Documentation showed no transfer summary was provided to the in-patient service provider. Patient #13 A review of the clinical record documented discharge from the agency on 12/09/21 for non-compliance. Documentation showed no discharge summary was provided to the physician service provider. Patient #14 A review of the clinical record documented transfer from the agency on 12/13/21 to in-patient provider services and was later discharged from the agency on 12/17/21. Documentation showed no transfer/discharge summary was provided to the in-patient service provider or to the physician service provider. Patient #15 A review of the clinical record documented transfer from the agency on 01/06/22 to in-patient provider services and was later discharged from the agency to hospice services. Documentation showed no transfer/discharge summary was provided to the in-patient service provider. Patient #16 A review of the clinical record documented discharge from the agency on 05/02/22 to in-patient SNF provider services. Documentation showed no transfer summary was provided to the in-patient SNF service provider. Patient #17 A review of the clinical record documented transfer from the agency on 03/28/22 to in-patient provider services. Documentation showed no transfer summary was provided to the physician service provider. On 05/17/22 at 4:00 p.m., Staff B stated no transfer/discharge summaries were sent to the physician service provider or to the receiving service providers for Patients #5, 13, 14. 15, 16 and #17.