Every finding on record at Saint Francis Hospital, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 02/24/25 to 02/25/25. 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 from 02/24/25 to 02/25/25. An entrance conference was conducted with Staff A, B, C, D, E and F. 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, E, F, G, H, I, J, K and L. Standard level deficiencies were cited as a result of the survey. Glossary: EMR electronic medical record EMS emergency medical services HHA Home Health Agency PT Physical Therapist POC Plan of Care SN skilled nurse

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 updated with current ordered medications for one (Patient #4) of 17 patients. Findings: Patient #4 A review of a POC dated 02/17/25 to 04/17/25 showed a start of care medication profile dated 02/17/25 by the admitting Physical Therapist. Documentation showed clindamycin (a systemic antibiotic) 300 mg every day with a start date of 07/31/24 and doxycycline 100 mg (a systemic antibiotic) every day with a start date of 07/31/24. Documentation showed no end date for the antibiotic regimen or indication for use and showed no follow up review with the residential facility, no physician notifications, and no change in orders. On 02/25/25 at 2:07 p.m., Staff G stated documentation showed no follow up review with the residential facility, and no physician notifications by the PT to verify continued use and/or indication for use.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a discharge summary for one (Patients #17) of 17 patients. Findings: Patient #17 A review of the clinical record showed the patient was discharged from agency on 01/26/25 for patient refusal of services. Documentation showed no discharge summary was completed. On 02/25/25 at 3:05 p.m., Staff G stated the agency did not complete a discharge summary for patient #17 because of a software system error.

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. SN interventions for wound site management were removed from the POC at the time of recertification for continued services for one (Patients #2) of 17 patients. 2. SN intervention for assessment and instruction for management of pain showed no pain reporting parameters to report to the physician for 11 (Patients #2, 3, 6, 7, 9, 11, 12, 14, 15, 16 and #17) of 17 patients. 3. SN intervention for assessment, instruction and urinary catheter change every month did not identify a last changed or due date of intervention for two (Patients #5 and #10) of 17 patients. Findings: Patient #2 A review of the POC dated 02/01/25 to 04/01/25 showed orders for SN to assess and instruct the patient’s pain level every visit and showed orders for a healed wound site dated 07/03/24. SN visit notes documented the patient’s reported pain levels as 2/10 on 02/24/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 1:50 p.m., Staff G stated: 1. The POC documentation identified no pain reporting parameters to report to the physician and; 2. The wound care from a healed wound site should have been removed from the POC at the time of the patient’s recertification for continued services. Patient #3 A review of the POC dated 01/04/25 to 03/04/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 2/10 on 01/20/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:05 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #5 A review of the POC dated 02/06/25 to 04/06/25 showed orders for SN to assess and instruct the patients’ health conditions and perform urinary intervention to change catheter 16 French /10 cubic centimeter every month. Documentation did not identify a last changed or due date of intervention and showed no physician notifications and no change in orders. On 02/25/25 at 2:10 p.m., Staff G stated the POC documentation identified no last changed or due date of intervention. Patient #6 A review of the POC dated 01/30/25 to 03/30/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 5/10 on 02/06/25 and 6/10 on 02/14/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:15 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #7 A review of the POC dated 01/23/25 to 03/23/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 1/10 on 02/10/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:20 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #9 A review of the POC dated 02/05/25 to 04/05/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:25 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #10 A review of the POC dated 01/18/25 to 03/18/25 showed orders for SN to assess and instruct the patients’ health conditions and perform urinary intervention to change catheter 16 French /10 cubic centimeter every month. Documentation identified the due date of intervention as 11/20/23 (date from prior certification period) and showed no physician notifications and no change in orders. On 02/25/25 at 2:30 p.m., Staff G stated the POC documentation identified a prior due date of intervention and gave no last changed date. Patient #11 A review of the POC dated 01/23/25 to 03/23/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:35 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #12 A review of the POC dated 01/16/25 to 03/16/25 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 3/10 on 01/20/25, 3/10 on 01/23/25, 4/10 on 01/27/25, and 5/10 on 02/06/25. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:20 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #14 A review of the POC dated 09/13/24 to 11/11/24 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:50 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #15 A review of the POC dated 12/28/24 to 02/25/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 2:55 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #16 A review of the POC dated 09/14/24 to 11/12/24 showed orders for SN to assess and instruct the patient’s pain level every visit. SN visit notes documented the patient’s reported pain levels as 7/10 on 09/17/24 and 5/10 on 10/02/24. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 3:00 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician. Patient #17 A review of the POC dated 01/26/25 to 03/26/25 showed orders for SN to assess and instruct the patient’s pain level every visit. Documentation showed no pain reporting parameters to report to the physician, no physician notifications and no change in orders. On 02/25/25 at 3:05 p.m., Staff G stated the POC documentation identified no pain reporting parameters to report to the physician.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for four (Patients #1, 6, 11 and #14) of 17 patients. Findings: Patient #1 A review of a plan of care dated 01/22/25 to 03/22/25 documented a primary diagnosis of non-pressure ulcer to the left lower extremity and showed a SN visit frequency and duration of two times a week for two weeks, then one time a week for seven weeks. Documentation showed patient refusal of wound site care visits on 02/19/25 and 02/21/25 showed the missed visit alerts were auto faxed to the physician with no follow up. Documentation showed no instruction for alternate caregivers to perform the wound site care interventions. The documentation showed no direct physician coordination of care communications as follow up to the patient’s refusals of SN visits and showed no changes in orders. On 02/25/25 at 1:45 p.m., Staff G stated the missed visit alerts for patient #1 that were auto faxed by the clinical record computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s refusal of care. Patient #6 A review of a plan of care dated 01/30/25 to 03/30/25 documented a primary diagnosis of pressure ulcer to the left buttock and showed a SN visit frequency and duration of one time a week for one week, two times a week for three weeks, then one time a week for five weeks. A SN visit note dated 02/14/25 showed the patient complained of chest pain and EMS was called to the residence. After the EMS assessment the patient refused transport to a hospital emergency medicine department. Documentation showed a communication alert was auto faxed to the physician with no follow up. The documentation showed no direct physician coordination of care communications as follow up to the patient’s incidence of chest pain complaints and showed no changes in orders. On 02/25/25 at 2:15 p.m., Staff G stated the communication alert for patient #6 that was auto faxed by the clinical record computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in condition. Patient #11 A review of a plan of care dated 01/23/25 to 03/23/25 documented a primary diagnosis of hypertensive heart disease with heart failure and showed a home health aide visit frequency and duration of one time a week for one week, two times a week for three weeks, then one time a week for five weeks. Documentation showed patient refusal of visits on 01/24/25, 01/31/25, 02/03/25, 02/06/25 and on 02/07/25 and showed the missed visit alerts were auto faxed to the physician with no follow up. The documentation showed no direct physician coordination of care communications as follow up to the patient’s refusals of home health aide visits and showed no changes in orders. On 02/25/25 at 2:35 p.m., Staff G stated the missed visit alerts for patient #11 that were auto faxed by the clinical record computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s refusal of care. Patient #14 A review of a plan of care dated 09/13/24 to 11/11/24 documented a primary diagnosis of hypertension and showed a SN visit frequency and duration of one day one, then three times a week for three weeks. Documentation showed the patient was discharged to hospice care services on 10/04/24. Documentation showed no physician coordination of care communications prior to the patient’s discharge from home health services and showed no changes in orders. On 02/25/25 at 2:50 p.m., Staff G stated the SN should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in condition prior to discharge from home health services.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: SN conducted urinary catheter change intervention as ordered by the physician for one (Patient #2) of 17 patients; SN reported to the physician blood pressure readings outside of reporting parameters for one (Patient #11) of 17 patients and; SN reported to the physician weight readings outside of reporting parameters for one (Patient #15) of 17 patients. Patient #2 A review of the POC dated 02/01/25 to 04/01/25 showed orders for SN to perform suprapubic urinary catheter change intervention using a 22 French / 30 cubic centimeter every month. Documentation showed during a SN visit conducted on 02/24/25, a 22 French / 5 cubic centimeter catheter over inflated to 10 cubic centimeter was used to perform the intervention. Documentation showed no physician notifications and no change in orders. On 02/25/25 at 1:50 p.m., Staff G stated the SN should have used the catheter as ordered in the plan of care by the physician. Patient #11 A review of the POC dated 01/23/25 to 03/23/25 showed orders for SN to conduct assessment and monitoring of patient blood pressure every visit and report to the physician reading outside of the 150 systolic reporting parameter. During SN visit conducted on 01/29/25 documentation showed a blood pressure reading of 160/62. Documentation showed no physician notifications and no change in orders. On 02/25/25 at 2:35 p.m., Staff G stated the SN should have notified the physician of the blood pressure reading as ordered on the POC. Patient #15 A review of the POC dated 12/28/24 to 02/25/25 showed orders for SN to conduct assessment and monitoring of patient weight every visit and report to the physician reading outside of the five-pound weight gain in one week reporting parameter. Documentation showed during SN visit conducted on 01/06/25 the patient’s weight was 68.5 kg and on 01/13/25 a weight of 70.8 kg (5.06-pound weight gain). Documentation showed no physician notifications and no change in orders. On 02/25/25 at 3:05 p.m., Staff G stated the SN should have notified the physician of the patient’s weight gain of 5.06 pounds in one week as ordered on the POC.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit note documentation was completed for two (Patients #1 and #3) of 17 patients. Findings: Patient #1 A review of the POC dated 01/22/25 to 03/22/25 showed orders for SN to assess, instruct and monitor patients’ health conditions and perform wound site care each visit. SN visit notes dated 02/05/25 and 02/14/25 documented no patient response to the wound site care interventions. On 02/05/25 at 1:45 p.m., Staff G stated SN clinical visit notes for 02/05/25 and 02/14/25 documented no patient response to the interventions. Patient #3 A review of the POC dated 01/04/25 to 03/04/25 showed orders for SN to assess, instruct and monitor patients’ pain each visit. SN visit note dated 01/05/25 documented no pain severity level reported by the patient. On 02/05/25 at 2:05 p.m., Staff G stated SN clinical visit notes for 01/05/25 documented no pain severity level reported by the patient.

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 completed transfer/discharge summaries were provided timely to receiving service providers for four (Patients #11, 14, 16 and #17) of 17 patients. Findings: Patient #11 A review of the clinical record showed the patient was transferred to in-patient hospital care on 02/14/25. Documentation showed a transfer summary, which was provided to the in-patient hospital service provider on 02/17/25 (3 days after the date of transfer). Patient #14 A review of the clinical record showed the patient was discharged to hospice care on 10/04/24. Documentation showed no discharge summary was provided to the hospice service provider, patient/caregiver or physician. Patient #16 A review of the clinical record showed the patient was transferred to in-patient hospital care on 10/09/24. Documentation showed a transfer summary, which was provided to the in-patient hospital service provider on 10/14/24 (5 days after the date of transfer). Patient #17 A review of the clinical record showed the patient was discharged from home health services on 01/26/25. Documentation showed a discharge summary was provided to the physician medical provider on 01/30/25 (4 days after the date of discharge). On 02/25/25 at 2:35 p.m. to 3:05 p.m., Staff G stated the transfer/discharge summaries for patients #11, 14, 16 and #17 were not provided to the receiving service providers timely.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/25/22 to 04/26/22. A deficiency was cited as a result of the Emergency Preparedness Program survey.

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 required staff contact information for the agency for 366 patients and all employees. Findings: A review of administrative records showed no documentation the Emergency Preparedness Communication Plan included staff contact information. On 04/25/22 at 12:30 p.m., Staff B stated the Emergency Preparedness Communication Plan did not include staff contact information for the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/25/22 through 04/26/22 An entrance conference was conducted with Staff A. 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, C, D, E, F and G. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: OT Occupational Therapy PT Physical Therapy QAPI Quality Assessment Performance Improvement SN Skilled Nursing

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 visits were conducted as ordered by the physician for two (Patients #1 and #2) of 17 patients;OT visits were conducted as ordered by the physician for one (Patient #2) of 17 patients;PT visits were conducted as ordered by the physician for one (Patient #4) of 17 patients;SN staff perform wound care as ordered by the physician for one (Patient #8) of 17 patients; andSN staff monitored patient weight as ordered by the physician for one (Patient #14) of 17 patients. Findings: Patient #1 A review of the POC dated 01/22/22 to 03/22/22 showed a SN visit frequency of one time a week for one week, then two times a week for eight weeks and one time a week for one week. Documentation showed during the week of 01/30/22 to 02/05/22 a SN visit was conducted on 01/31/22 and no SN visit was conducted on 02/04/22 (one visit missed). Documentation showed no physician notification of the missed visit, no change in orders, and no patient or caregiver refusal of the SN visit. On 04/25/22 at 1:15 p.m., Staff C stated the physician should have been notified of the missed SN visit for Patient #1 but was not. Patient #2 A review of the POC dated 09/30/21 to 11/28/21 showed a SN visit frequency of one time a week for one week, two times a week for two weeks, then one time a week for seven weeks and an OT visit frequency of two times a week for six weeks. Documentation showed during the week of 10/03/21 to 10/09/21 a SN visit was conducted on 10/05/22 (one visit conducted and one visit missed) and during the week of 10/17/21 to 10/23/21 no OT visits were conducted (two visits missed). Documentation showed no physician notification of the missed visits, no change in orders, and no patient or caregiver refusal of the visits. On 04/25/22 at 1:30 p.m., Staff C stated the physician should have been notified of the missed SN and OT visits for Patient #2 but was not. Patient #4 A review of the POC dated 01/16/22 to 03/16/22 showed a PT visit frequency of three times a week for four weeks, then two times a week for two weeks. Documentation showed during the week of 01/30/22 to 02/05/22 a PT visit was conducted on 01/31/22 (one visit conducted and two visits missed), during the week of 02/06/22 to 02/12/22 a PT visit was conducted on 02/07/22 and 02/11/22 (two visits conducted and one visit missed) and during the week of 02/13/22 to 02/19/22 no PT visits were conducted (two visits missed). Documentation showed no physician notification of the missed visits, no change in orders, and no patient or caregiver refusal of the visits. On 04/25/22 at 1:45 p.m., Staff C stated the physician should have been notified of the missed PT visits for Patient #4 but was not. Patient #8 A review of the POC dated 04/09/22 to 06/07/22 showed a SN frequency of one time a week for nine weeks and for SN to assess a wound site and perform wound care to the left lower extremity. A review of clinical notes dated 04/11/22 and 04/18/22 showed no wound care to the left lower extremity performed but wound care to the left ischium was conducted (no wound care ordered for the left ischium on the POC). Documentation showed on 04/11/22 and on 04/18/22 the wound site identified as the left ischium was cleansed with normal saline, Santyl ointment (a tissue debridement medication) was applied and the site was covered with a gauze dressing (wound care not ordered by the physician on the updated POC). Documentation showed no physician notification of change in wound status to the left lower extremity, no POC update of the left ischium wound site, no change in orders, and no patient or caregiver refusal of the ordered wound care to the left lower extremity. On 04/25/22 at 2:00 p.m., Staff C stated the physician should have been notified of the resolved wound sites to the left lower extremity and the wound site and orders for wound care for the left ischium should have been included on the POC for Patient #8 but was not. Patient #14 A review of the POC dated 04/10/22 to 06/08/22 showed a SN frequency of two times a week for two weeks, then one time a week for seven weeks and for SN to monitor patient’s weight. Clinical documentation showed skilled nurse visits conducted on 04/10/22, 04/14/22, and 04/18/22 showed no weight monitoring documented. Documentation showed no patient/caregiver refusal of weight monitoring, physician notification of change in weight status and no change in orders. On 04/26/22 at 2:00 p.m., Staff C stated SN staff should have weighed the patient as ordered and notified the physician of changes in the patient’s as directed in the weight reporting parameters on the POC for Patient #14 but did not.

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 366 patients and all employees. Findings: A review of ann agency policy titled, "Home Care Performance Plan," stated, "Directors are responsible [to] assign sufficient staff and provide adequate time for staff to participate in performance improvement. The home care quality assurance [committee] is responsible for coordinating organizational performance improvement activities. At a minimum data will be collected and relevant information from activities is integrated into performance improvement activities. Data will be evaluated via comparison and analysis is performed. The agency uses the information to identify changes to improve care, treatment, safety and services. Follow up measurement will be performed at appropriate intervals. Performance Improvement activities will be documented, and reports furnished." A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data monitored, measured, analyzed, tracked or evaluated by the agency. Documentation showed no QAPI meeting for 2020; one QAPI meeting on 10/25/21 (limited data without attendant identification/authentication), and one QAPI meeting on 12/21/21 (limited data with attendant identification/authentication) and no meeting documentation for 01/01/22 through 04/26/22. On 04/26/22 at 10:00 a.m., Staff B stated: 1. the agency did not meet quarterly and only prepared a limited yearly report of activities during calendar years 2020, 2021 and no meeting or reporting has taken place for 01/01/22 through 04/26/22 and 2. documentation showed no measurable improvement and no measurements, analysis, tracking or evaluation of data by the agency.

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 366 patients and all employees. Findings: A review of administrative records showed no ongoing quarterly QAPI program activities to improve the care, services, and operations for the agency. Documentation showed no QAPI meeting for 2020; one QAPI meeting on 10/25/21 (limited data without attendant identification/authentication), and one QAPI meeting on 12/21/21 (limited data with attendant identification /authentication) and no meeting documentation for 01/01/22 through 04/26/22. On 04/26/22 at 10:00 a.m., Staff B stated the agency: 1. did not meet quarterly; 2. only prepared a limited yearly report of activities during calendar years 2020, 2021; and 3. no meeting or reporting had taken place for 01/01/22 through 04/26/22.

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 of a PIP through their QAPI Program for 01/01/22 through 04/26/22 for 366 patients and all employees. Findings: A review of administrative QAPI records showed no initiation, review, data analysis, or status of PIPs for 01/01/22 through 04/26/22. On 04/26/22 at 10:00 a.m., Staff B stated the agency had no documentation which showed PIP activities for 01/01/22 through 04/26/22.

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 366 patients and all employees. Findings: A review of QAPI administrative records showed no documentation of infection control surveillance data for calendar years 2020, 2021 and 01/01/22 to 04/26/22. On 04/26/22 at 10:00 a.m., Staff B stated infection surveillance activities were not reported through the agency's QAPI program.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on a record review and interview, the agency failed to ensure speech therapy staff were available to meet patient care service needs for two (Patient # 6 and Patient # 16) of 17 patients. Findings: Patient #6 A POC dated 04/06/22 to 06/04/22 showed a speech therapy visit frequency of one time a week for four weeks. A review of the clinical record showed during the week of 04/10/22 to 04/16/22 the speech therapy visit was missed due to no speech therapist available. Documentation showed no patient/caregiver refusal of the visit, physician notification or change in orders. Patient #16 A POC dated 03/25/22 to 05/23/22 showed a speech therapy visit frequency of two time a week for one week and then two times a week for four weeks. A review of the clinical record showed during the week of 04/10/22 to 04/16/22 the speech therapy visit was missed due to no speech therapist not. Documentation showed no patient/caregiver refusal of the visit, physician notification or change in orders. On 04/25/22 at 12:30 p.m., Staff C stated no speech therapist was available for the missed visit for Patients #6 and #16.

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-disciplinary skilled professional staff were available to participate and provide input into the agency QAPI program for 366 patients and all employees. Findings: A review of administrative records showed no ongoing quarterly multi-disciplinary QAPI program activities for the agency. Documentation showed no QAPI meeting for 2020; one QAPI meeting on 10/25/21 (limited data without attendant identification/authentication), and one QAPI meeting on 12/21/21 (limited data with attendant identification/authentication) and no meeting documentation for 01/01/22 through 04/26/22. On 04/26/22 at 10:00 a.m., Staff B stated: 1. the agency did not meet quarterly only prepared a yearly report of limited activities during calendar years 2020 and 2021 and no meeting or reporting has taken place for 01/01/22 through 04/26/22. 2. There was no documentation of milti-disciplinary QAPI team activities.

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 activities of an operating budget or capital expenditure plan for the agency for calendar year's 2020, 2021 and 01/01/22 through 04/26/22 effecting 366 patients and all employees. Findings: A review of administrative records showed no governing body oversite activities of an operating budget or capital expenditure plan for the agency for calendar year's 2020, 2021 and 01/01/22 to 04/26/22. On 04/26/22 at 12:00 p.m., Staff B stated there was no documentation which showed governing body resource allocation oversight for the agency.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed discharge summary was provided for two (Patients #4 and #5) of 17 patients. Findings: Patient #4 A review of the clinical record documented discharge from the agency on 02/22/22 to hospice service provider. Documentation showed no discharge summary was provided to the hospice service provider. Patient #5 A review of the clinical record documented discharge from the agency on 12/07/21 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. On 04/12/22 at 11:40 a.m., Staff C stated no discharge summary was sent to the receiving service providers for Patients #4 and #5.