Every finding on record at Simplifi Home Health LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/08/24 to 10/09/24. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure administrative policies and procedures related to Emergency Preparedness Plan patient data management were in place for all patients and employees. Findings: A review of administrative records showed no administrative policies and procedures related to an Emergency Preparedness Plan patient data management for the agency. On 10/09/24 at 9:15 a.m., Staff B stated the agency did not have administrative policies and procedures related to an Emergency Preparedness Plan patient data management for the agency.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation, and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: Administrative records showed no administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency were in place. On 10/09/24 at 9:15 a.m., Staff B stated the agency did not have an Emergency Preparedness Plan with administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/08/24 to 10/09/24. An entrance conference was conducted with Staff C. The survey process was explained. Questions were answered. Staff C was identified as an initial contact person for administrative issues; and Staff A and B were identified as additional contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the survey. Glossary: OT occupational therapy PT physical therapy POC plan of care PIP performance improvement project QAPI quality assessment and performance improvement SN skilled nurse

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator’s name and contact information related to complaint and grievance procedures for the agency was a part of the admission packet information for all patients. Findings: Review of administrative records (start of care patient information packet/booklet) showed no agency administrator’s name and contact information for the agency. Patients #1, 3, 4 and #5 On 10/08/24 during in home visits for patients #1, 3, 4 and #5, the patients were not able to identify the agency administrator’s name or contact information. Review of the in-home patient folders (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures for the agency. On 10/09/24 at 9:15 a.m., Staff B stated the administrator’s name and contact information was not in the packet/booklet information given to the patients at the time of admission to the agency.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure patient advisement of complaint and grievance processes for the agency were included in patient admission packet information for four (Patients #1, 3, 4 and #5) of 11 patients reviewed. On 10/08/24, a review of patient admission packet information (forms for consent, Patient Rights, billing, complaint and grievance processes and introduction to the agency) showed no documentation of patient complaint and grievance procedures for the agency. From 12:00 a.m. to 3:00 p.m., clinical patient record reviews in the electronic medical records were completed for patients #1 to #11. Documentation showed no paper or electronic receipt of complaint and grievance processes for the agency. From 3:30 to 4:30 p.m., During in home visits for patients #1, 3, 4 and #5, the patients were not able to verbalize complaint and grievance processes for the agency. Review of the in-home patient folders (patient information packet) for the agency showed no documentation of advisement of complaint and grievance processes for the agency. On 10/09/24 at 9:15 a.m., Staff B stated the agency patient admission packet information (forms for consent, Patient Rights, billing, complaint and grievance processes, and introduction to the agency) showed no documentation of patient advisement of the complaint and grievance procedures for the agency.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure patient advisement of OSDH contact information were included in patient admission packet information for four (Patients #1, 3, 4 and #5) of 11 patients reviewed. Findings: On 10/08/24, a review of patient admission packet information (forms for consent, Patient Rights, billing, complaint and grievance processes and introduction to the agency) showed no documentation of OSDH contact information (hotline) as a part of the complaint and grievance processes for the agency. From 12:00 a.m. to 3:00 p.m., clinical patient record reviews in the electronic medical records were completed for patients #1 to #11. Documentation showed no paper or electronic receipt of OSDH contact information as a part of the complaint and grievance processes for the agency. From 3:30 to 4:30 p.m., During in home visits for patients #1, 3, 4 and #5, the patients were not able to verbalize complaint and grievance processes for the agency. Review of the in-home patient folders (patient information packet) for the agency showed no documentation of advisement of OSDH contact information as a part of the complaint and grievance processes for the agency. On 10/09/24 at 9:15 a.m., Staff B stated the agency patient admission packet information (forms for consent, Patient Rights, billing, complaint and grievance processes, and introduction to the agency) showed no documentation of patient advisement of OSDH contact information as a part of the complaint and grievance processes for the agency.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care or communication with physicians were conducted prior to patient discharged from the agency for two (Patients #10 and 11) of 11 patients. Findings: Patient #10 A review of the clinical record showed the patient SOC was on 09/07/24. Documentation showed the patient was transferred with discharge from the agency on 09/16/24 to in-patient provider services. Documentation showed no coordination of care or communication with the physician and showed no documented reasons for the agency to discharge the patient for cause prior to the patient’s transfer with discharge from agency services. Patient #11 A review of the clinical record showed the patient was recertified for continued agency services for the POC dated 07/08/24 to 09/05/24. Documentation showed the patient was discharge from the agency on 09/03/24. Documentation showed no coordination of care or communication with the physician and showed no documented reasons for the agency to discharge the patient for cause prior to the patient’s discharge from agency services. On 10/09/24 at 12:00 p.m., Staff B stated patients #10 and #11: 1. Received no advance notice of discharge prior to discharge from agency services; and 2. Documentation showed no coordination of care or communication with the physician and showed no documented reasons for the agency to discharge the patients for cause prior to their discharge from agency services.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure start of care within 48 hours of referral for one (Patient #2) of 11 patients. Findings: Patient #2 A review of the clinical record showed a referral date of 05/30/24 and a SOC date of 06/04/24 (4 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 10/09/24 at 11:25 a.m., Staff B stated documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders.

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. PT interventions and goals for three (Patients #1, 4 and #10) of 11 patients; 2. OT interventions and goals for one (Patient #2) of 11 patients; and 3. Identified wound site care for one (Patient #2) of 11 patients. Findings: Patient #1 A review of the POC dated 08/23/24 to 10/21/24 showed orders for PT one time a week for nine weeks. Documentation showed no PT interventions and goals. Documentation showed no physician notifications, and no changes in orders. On 10/09/24 at 11:20 a.m., Staff B stated the POC for patient #1 did not include PT interventions and goals. Patient #2 A review of the POC dated 08/03/24 to 10/01/24 showed orders for OT two times a week for one week, then one time a week for three weeks; and SN to conduct wound site care one time a week for nine weeks, the POC did not identify a wound site. Documentation showed no OT interventions and goals. Documentation showed no physician notifications, and no changes in orders. On 10/09/24 at 11:25 a.m., Staff B stated the POC for patient #2 did not include OT interventions and goals and did not identify a wound site. Patient #4 A review of the POC dated 09/22/24 to 11/20/24 showed orders for PT one time a week for nine weeks. Documentation showed no PT interventions and goals. Documentation showed no physician notifications, and no changes in orders. On 10/09/24 at 11:40 a.m., Staff B stated the POC for patient #4 did not include PT interventions and goals. Patient #10 A review of the POC dated 09/07/24 to 11/05/24 showed orders for PT to evaluate week of 09/09/24. A communication note documented the PT frequency and duration was two times a week for eight weeks. Documentation showed no PT interventions and goals. Documentation showed no physician notifications, and no changes in orders. On 10/09/24 at 12:03 p.m., Staff B stated the POC for patient #10 did not include orders for PT frequency and duration two times a week for eight weeks and showed no PT interventions and goals.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were documented for PT for two (Patients #3 and 7) of 11 patients. Findings: Patient #3 A review of the POC dated 09/28/24 to 11/26/24 showed orders for PT to evaluate week of 09/09/24. A communication note documented the PT frequency and duration was one time a week for eight weeks. Documentation showed no orders for PT frequency and duration one times a week for eight weeks and showed no PT interventions and goals. Documentation showed no physician notifications, and no changes in orders. On 10/09/24 at 11:30 a.m., Staff B stated the POC for patient #3 did not include orders for PT frequency and duration one time a week for eight weeks and showed no PT interventions and goals. Patient #7 A review of a POC dated 09/09/24 to 11/07/24 showed documentation of a PT evaluation week of 09/04/24. A communication note documented the PT frequency and duration was one time a week for four weeks. Documentation showed no orders for PT frequency and duration one times a week for four weeks and showed no PT interventions and goals. Documentation showed no physician notifications, and no changes in orders. On 10/09/24 at 11:50 a.m., Staff B stated the POC for patient #7 did not include orders for PT frequency and duration one time a week for four weeks and showed no PT interventions and goals.

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 all patients and employees. Findings: A review of administrative QAPI records for calendar years 2023 and 01/01/24 to 10/05/24 showed no data collection sources or activities utilized in the analysis of data in the agency's QAPI Program for calendar year 2023. On 10/09/24 at 9:00 a.m., Staff B stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no program improvement data or analysis of collected data that showed improved quality of patient care for calendar year 2023.

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. 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 that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations for all patients and employees. Findings: A review of administrative QAPI records for calendar years 2023 and 01/01/24 to 10/05/24 showed no documentation of patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services, and operations for calendar year 2023. On 10/09/24 at 9:00 a.m., Staff B stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services, and operations for calendar year 2023.

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 selection, review and reporting of ongoing PIP data through the QAPI program for all patients and employees. Findings: A review of administrative QAPI program documents showed no PIP data reporting for calendar years 2023. On 10/09/24 at 9:00 a.m., Staff B stated QAPI program documentation showed no PIP selection or reporting of PIP data for calendar year 2023.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program for all patients and employees. Findings: A review of administrative records showed no governing body oversite of the conduction of a patient centered QAPI program for calendar year 2023 for the agency. On 10/09/24 at 9:00 a.m., Staff B stated administrative QAPI records showed no documentation of governing body oversite of the conduction of a patient centered QAPI program for calendar years 2023.

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 surveillance data was included in QAPI program activities for all patients and employees. Findings: A review of QAPI administrative records showed no documentation of infection control surveillance data through the QAPI program for calendar year 2023 and 01/01/24 to 06/30/24. On 10/09/24 at 9:00 a.m., Staff B stated infection surveillance activities were not reported through the agency's QAPI program for calendar year 2023 and 01/01/24 to 06/30/24.

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 services were provided as ordered on the POC’s: 1. SN to conduct assessment of site and perform wound care every visit for one (Patient #2) of 11 patients; 2. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for one (Patient #5) of 11 patients; 3. SN to conduct assessment of patient pulse every visit and notify the physician of pulse less than 90 for one (Patient #6) of 11 patients; and 4. SN to administer medication one time a week for one (Patient #8) of 11 patients. Findings: Patient #2 A review of an updated POC dated 08/03/24 to 10/01/24 showed orders for SN to conduct wound care to site and complete a dressing change every visit: cleanse with wound cleanser, apply Versatel 1, cover with a Optifoam dressing. Documentation showed during SN visit dated 09/09/24 no wound site care and dressing change was performed. Documentation showed no patient refusal of wound care, no physician notification, and no changes in orders. On 10/09/24 at 11:25 a.m., Staff B stated SN should have followed the POC and conducted the wound site care and dressing change during the visit. Patient #5 A review of the POC dated 09/26/24 to 11/24/24 showed orders for SN to conduct assessment of patient weight every visit. Documentation showed no monitoring of the patient’s weight during SN visits conducted on 09/03/24 and on 10/07/24. Documentation showed no patient refusal of weight, no physician notifications and showed no changes in orders. On 10/09/24 at 11:42 a.m., Staff B stated SN should have followed the POC and assessed the patient’s weight during the visit. Patient #6 A review of a POC dated 09/15/24 to 11/13/24, showed orders for SN to monitor patient’s pulse rate and notify physician if pulse rate less than 90. Documentation showed during SN visits conducted on 09/18/24 the patient’s pulse rate was 80, on 09/25/24 the patient’s pulse rate was 74 and on 10/02/24 the patient’s pulse rate was 79. Documentation showed no physician notifications and showed no changes in orders. On 10/09/24 at 11:46 a.m., Staff B stated SN should have followed the POC and notified the physician of pulse rates less than 90 and obtain an order to change the reporting parameter to less than 60. Patient #8 A review of a POC dated 08/05/24 to 10/03/24, showed orders for SN to administer medication Trulicity subcutaneous injection one time a week. Documentation showed during SN visits conducted on 08/07/24, 08/21/24 and on 08/28/24 no medication was administered by the SN. Documentation showed no physician notifications or changes in orders. On 10/09/24 at 11:52 a.m., Staff B stated SN should have notified the physician that medication was not available to administer during SN visits and obtained orders from the physician to change the POC.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: Administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar year 2023 and for 01/01/24 to 10/08/24. On 10/09/24 at 9:00 a.m., Staff B stated documentation showed no multi-disciplined skilled professional staff participation in ongoing QAPI program activities in calendar year 2023 and for 01/01/24 to 10/08/24 for the agency.

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. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023 and 01/01/24 to 10/08/24; and 2. Agency program evaluation for calendar year 2023 and 01/01/24 to 10/08/24 for all patients and employees. Findings: Administrative records showed no governing body over-site and responsibility for the agency’s operating budget, capital expenditure plan or agency’s program evaluation for calendar year 2023 and 01/01/24 to 10/08/24. On 10/09/24 at 9:30 a.m., Staff B stated documentation showed no: 1. Ongoing governing body oversite and responsibility for the agency’s operating budget, capital expenditure plan; and 2. Oversight of the agency’s program evaluation for calendar year 2023 and 01/01/24 to 10/08/24.

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 ensure PT discharge clinical visit note documentation was completed for one (Patient #7) of 11 patients. Findings: Patient #7 A review of the POC dated 09/09/24 to 11/07/24 showed orders for PT visit frequency of one time a week for four weeks. Documentation showed PT discharge visit was scheduled on 10/02/24. Documentation showed no coordination of care related to delayed or missed discharge visit note. On 10/09/24 at 11:50 a.m., Staff B stated visit documentation for 10/02/24 PT discharge was not completed/submitted.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness survey at the agency on 10/11/21 through 10/12/21. No deficiencies were cited as a result of the Emergency Preparedness survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/11/21 through 10/12/21. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C and D. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: OT Occupational Therapy PIPs Performance Improvement Projects PT Physical Therapy/Physical Therapist Pts Patients QAPI Quality Assessment and Performance Improvement

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 PIP documentation was thorough and inclusive of initiation date(s), agency action and reasons for PIP initiation for three of three PIPs reviewed which had the potential to reduce PIP success for all patients and agency employees from January 2019 to September 30, 2021. Findings: A review of QAPI, PIP and administrative records for 2019, 2020 and January - September 2021 showed three PIPs which failed to include the following: 1. Date of Initiation 2. Date(s) problem occurred 3. Identification of specific interventions 4. Review and evaluation 5. Status of PIP On 10/12/21 at 1:00 pm, Staff A stated the PIPs did not include date of initiation, when problem was discovered, specific interventions, review, evaluation or status of the three PIPs.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's governing body failed to ensure PIPs were evaluated for effectiveness for all patients on service during calendar years 2019, 2020 and January through September 2021. Findings A review of PIPs showed undated PIPs and no dates of initiation, no PIP review, no specific interventions, implementation of new interventions, no review dates or closure dates. A review of governing body minutes showed no action to ensure PIPs were evaluated for effectiveness. On 10/12/21 at 1:03 pm, Staff A stated the governing body reviewed and approved the QAPI program but documentation showed no evaluation of PIPs for effectiveness.

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 skilled professional services were provided in accordance with the POC frequency for two (Patient #6 and 8) of 12 patients. Findings: Pt #6 A review of the POC showed a skilled nurse frequency of twice a week for two weeks and then once a week for seven weeks for certification period of 08/17/21 - 10/15/21. Clinical visit notes showed one of two ordered visits completed the week of 08/29/21 - 09/04/21. Pt #8 A review of the POC showed a skilled nurse frequency of once a week for nine weeks for certification period 08/09/21 - 10/07/21 and a PT frequency once a week for eight weeks beginning the week of 08/16/21. Clinical notes showed no skilled nursing visit the week of 09/26/21 - 10/02/21 (one visit missing) and no PT visits completed during the certification period (8 visits missing). On 10/12/21 at 1:05 pm, Staff A stated: 1. the ordered frequency of twice a week for two weeks was not followed for Pt #6. 2. the ordered frequency for nursing visits was not followed for Pt #8. 3. there were no PT visits completed during the certification period for Pt #8.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency administrator of record was currently certified as a home care administrator. This had the potential to affect the oversight and delivery of care to all current employees and 247 current patients. Findings: A reviw of OAC 310:664 (home care administrator rules) documented the minimum criteria for the issuance, maintenance, and renewal of a home care administrator certificate for home care administrators in the State of Oklahoma. A review of OAC 310:662 (home care agency rules) documented requirements for the home care administrator to be certified. A review of administrative records showed Staff A appointed as the current Administrator. A review of the the administrator's certificate showed an expiration date of 07/31/21. On 10/12/21 at 10:50 am, Staff A stated: 1. She was in the process of renewing her administrator's certificate; 2. She made a couple of inquiries (previously) and resubmitted her application. 3. The alternate supervising nurse had a current administrator's certificate.