Every finding on record at Shepherd Home Health, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/25/24 to 06/26/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 06/25/24 to 06/26/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B, C and D were identified as the contact persons for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff B, C, D and F. Deficiencies were cited as a result of the re-certification survey. GLOSSARY: QAPI Quality Assessment and Performance Improvement

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an individualized plan of care included goals pertaining to the primary diagnosis for one (Patient #5) of 10 patients. Patient #5 A review of the plan of care dated 04/03/24 to 06/01/24 showed a primary diagnosis of diabetes mellitus type II and documented no individualized goals pertaining to the management of the primary diagnosis. On 06/26/24 at 1:50 pm, Staff D stated the plan of care for Patient #5 failed to develop goals in relation to the primary diagnosis.

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 a patient centered QAPI Program was developed to measure, analyze and track quality indicators for all 134 patients and employees. A review of administrative records showed no ongoing patient centered QAPI program which evaluated quality indicators for measurable improvement to help improve health outcomes and quality of care. No quality indicators were collected, monitored or evaluated by the agency for 2023 and January 1, 2024, through June 26, 2024. On 06/26/24 at 12:40 pm, Staff B stated there was no documentation of the QAPI program evaluating quality indicators for measurable improvement to help improve health outcomes and quality of care and no documentation of quality indicators which were collected, monitored or evaluated by the agency for the Calander year of 2023 and from January 1, 2024, through June 26, 2024.