Every finding on record at Stewart Healthcare Enterprises, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/27/24 to 02/28/24. Standard deficiencies were cited as a result of the Emergency Preparedness Program survey.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. 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 and contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of administrative records showed no administrative processes and/or resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency. On 02/28/24 at 2:05 p.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.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for calendar years 2022 and 2023 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for calendar years 2022 and 2023. On 02/28/24 at 2:05 pm, Staff B stated the agency had no emergency preparedness disaster declarations, table-top exercises, drills, community drills or plan activation events for calendar years 2022 and 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/27/24 to 02/28/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact person for 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 survey. Glossary: EP Emergency Preparedness HHA Home Health Agency HHCOC Home Health Change of Care IM intramuscular mg milligram ml milliliter POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse SQ subcutaneous

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 advance beneficiary notice and/or HHCOC notice was provided to two (Patients #6 and #8) of nine patients. Findings: Patient #6 A review of the clinical record showed no advance notice of discharge or home health change of care notice or physician communications prior to discharge from the agency on 02/20/24 for no payer source for services. On 02/28/24 at 3:05 p.m., Staff A stated there was no ABN or HHCOC notices in the clinical record or physician communications prior to being discharged from the agency for no payer source for services. Patient #8 A review of the clinical record showed no advance notice of discharge or home health change of care notice or physician communications prior to discharge from the agency on 12/29/23 for no payer source for services. On 02/28/24 at 3:12 p.m., Staff A stated there was no ABN or HHCOC notices in the clinical record or physician communications prior to being discharged from the agency for no payer source for services.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POCs included medication administration interventions for two (Patients #2 and #3) of nine patients. Findings: Patient #2 A review of the POC dated 02/05/24 to 04/04/24 showed orders for SN visit frequency of one time a week for nine weeks. Documentation showed the POC medication profile stated Ozempic 2 mg/1.5 ml once a week and a POC narrative of SN administer IM or SQ medications as ordered. POC documentation showed no order for SN to administer Ozempic 1 mg/0.75 ml subcutaneously every week. SN visit documentation dated 02/09/24, 02/16/24 and 02/23/24 documented SN administered Ozempic 1 mg/0.75 ml SQ each visit. Documentation showed no physician notifications and no change in orders. On 02/28/24 at 2:50 p.m., Staff A stated the POC for patient #2 showed no order for SN to administer Ozempic 1 mg/0.75 ml subcutaneously every week. Patient #3 A review of the POC dated 02/13/24 to 04/12/24 showed orders for SN visit frequency of one time a day for 60 days. Documentation showed the POC medication profile stated Lantus 100 unit/ml 25 units inject subcutaneous once a day and a POC narrative documented home health for management of insulin administration and oversight of diabetic management. POC documentation showed no order for SN to administer Lantus 100 unit/ml 25 units subcutaneously every day. SN visit documentation dated 02/14/24, 02/15/24, 02/16/24, 02/17/24, 02/18/24, 02/19/24, 02/20/24, 02/21/24, 02/22/24, 02/23/24, 02/25/24, 02/25/24 and 02/26/24 documented SN administered Lantus 100 unit/ml 25 units subcutaneously each visit. Documentation showed no physician notifications and no change in orders. On 02/28/24 at 2:55 p.m., Staff A stated the POC for patient #3 showed no order for SN to administer Lantus 100 unit/ml 25 units subcutaneously every day.

Communication with all physicians CFR(s): 484.60(d)(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 physician notification of changes in patient care for two (Patients #2 and #3) of nine patients. Findings: Patient #2 A review of a plan of care dated 02/05/24 to 04/04/24 documented a diagnosis of diabetes mellitus type II showed orders for SN to conduct finger stick blood sugar check every visit. SN visit documentation dated 02/09/24, 02/16/24 and 02/23/24 documented the patient had no glucometer to conduct finger stick blood sugar check. Documentation showed no physician notification the patient had no glucometer to conduct finger stick blood sugar check and showed no change in orders. On 02/28/24 at 2:50 p.m., Staff A stated the physician should have been notified of the patient had no glucometer to conduct finger stick blood sugar check during the home visits. Patient #3 A review of the POC dated 02/13/24 to 04/12/24 documented a diagnosis of diabetes mellitus type II showed orders for SN to monitor for presence of skin lesions on lower extremities and report changes in status to physician. SN visit documentation dated 02/14/24 and on 02/15/24 documented the presence of blood blisters on bilateral heels left open to air. Documentation showed no physician notification and showed no change in orders. On 02/28/24 at 2:55 p.m., Staff A stated the physician should have been notified of the presence of blood blisters on bilateral heels during the home visits.

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: 1. OT conducted visit frequency as ordered on the POC for one (Patient #2) of nine patients; 2. SLP conducted visit frequency as ordered on the POC for one (Patient #2) of nine patients; 3. SN conducted monitoring of patient weight for one (Patient #2) of nine patients; 4. SN conducted monitoring of finger stick blood sugar for two (Patients #2 and #4) of nine patients and; 5. SN conducted visit frequency as ordered on the POC for three (Patients #6, 8 and #9) of nine patients. Findings: Patient #2 A review of a plan of care dated 02/05/24 to 04/04/24 showed orders for SN to conduct finger stick blood sugar check and monitor the patient’s weight every visit and showed documentation of OT visit frequency of one time a week for nine weeks and SLP visit frequency of one time a week for nine weeks. SN visit documentation dated 02/09/24, 02/16/24 and 02/23/24 showed no finger stick blood sugar or patient’s weight monitoring conducted. Documentation showed during the week of 02/12/24 to 02/18/24 no OT visit (one visit ordered, no visit conducted) and during the week of 02/19/24 to 02/25/24 no SLP visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/28/24 at 2:50 p.m., Staff A stated the physician should have been notified of the patient had no finger stick blood sugar check or monitoring of the patient’s weight during the home SN visits and no OT or SLP home visits were conducted during the weeks of 02/12/24 to 02/18/24 and 02/19/24 to 02/25/24. Patient #4 A review of a plan of care dated 02/05/24 to 04/04/24 showed orders for SN to conduct finger stick blood sugar check every visit. SN visit documentation dated 01/10/24, 01/24/24, 02/09/24 and 02/22/24 showed no finger stick blood sugar conducted. Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 02/28/24 at 3:00 p.m., Staff A stated the physician should have been notified of the patient had no finger stick blood sugar checks during the home SN visits Patient #6 A review of the plan of care dated 12/24/23 to 02/21/24 showed orders for SN visit frequency one time a week for eight weeks. Documentation showed during the week of 01/21/24 to 01/27/24 no SN visits were conducted (one visit ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 02/28/24 at 3:05 p.m., Staff A stated SN should have conducted SN visits as ordered in the POC. Patient #8 A review of the plan of care dated 11/24/23 to 01/22/24 showed orders for SN visit frequency of one day one, one week one then, one time a week for nine weeks. Documentation showed during the weeks of 12/18/23 to 12/24/23 no SN visits were conducted (one visit ordered, no visits conducted) and 12/25/23 to 12/29/23 no SN visits were conducted (one visit ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 02/28/24 at 3:12 p.m., Staff A stated SN should have conducted SN visits as ordered in the POC. Patient #9 A review of the plan of care dated 01/18/24 to 03/17/24 showed orders for SN visit frequency of one day one, one week one then three times a week for eight weeks. Documentation showed during the weeks of 01/22/24 to 01/28/24 no SN visits were conducted (three visits ordered, one visit conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 02/28/24 at 3:22 p.m., Staff A stated SN should have conducted SN visits as ordered in 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: A review of administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2022 and 2023. On 02/28/24 at 11:55 a.m., Staff B stated QAPI program activities had no multi-disciplined skilled professional staff participation for the agency.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure completion of alternative training required to meet the qualifications of a Home Health Aide for one (Staff F) of five employees reviewed. Findings: Staff F A review of personnel records showed certification as a Long Term Care Aide. Documentation showed no Home Health Aide certification and showed no completion of alternative training required to meet the qualifications of a Home Health Aide. On 02/28/24 at 2:00 p.m., Staff C stated: 1. The agency did not require Home Health Aide certification for its home health aides and; 2. Staff F personnel record showed no completion of alternative training required to meet the qualifications of a Home Health Aide.

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure documentation which showed completion of alternative training requirements to meet the qualifications of a Home Health Aide for one (Staff F) of five employees reviewed. Findings: Staff F A review of personnel records showed certification as a Long Term Care Aide. Documentation showed no Home Health Aide certification and showed no documentation which showed completion of alternative training requirements to meet the qualifications of a Home Health Aide. On 02/28/24 at 2:00 p.m., Staff C stated: 1. The agency did not require Home Health Aide certification for its home health aides and; 2. Staff F personnel record showed no documentation of completion of alternative training requirements to meet the qualifications of a Home Health Aide.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided to the receiving service provider within 48 hours of notification of patient transfer for two (Patients #7 and #9) of nine patients. Findings: Patient #7 A review of the clinical record documented transfer from the agency to inpatient hospital service provider on 12/22/23. Documentation showed a transfer summary was not provided to the inpatient hospital service provider until 12/28/23 (six days from the date of transfer). Patient #9 A review of the clinical record documented transfer from the agency to inpatient hospital service provider on 01/30/24. Documentation showed a transfer summary was not provided to the inpatient hospital service provider until 02/09/24 (10 days from the date of transfer) and transfer from the agency to inpatient hospital service provider on 02/20/24. Documentation showed a transfer summary was not provided to the inpatient hospital service provider until 02/26/24 (six days from the date of transfer). On 02/28/24 at 3:05 p.m. to 3:22 p.m., Staff A stated no transfer summary was sent to the receiving service providers for Patients #7 and #9 within 48 hours of notification of patient transfer.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/20/21 to 04/22/21. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan which included required information related to all patients and resources for the agency. Findings: A review of administrative records showed a nursing staff call list. The Emergency Preparedness Communication Plan showed no required information related to patients and resources for the agency. On 04/22/21 at 10:00 a.m., Staff A stated the agency did not have a comprehensive Emergency Preparedness Communication Plan in place.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/20/21 through 04/22/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: CHHA Certified Home Health Aide MSW Medical Social Worker Pt's Patients PT Physical Therapy QAPI Quality Assurance Performance Improvement SN Skilled Nurse

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 notice of non-coverage was provided prior to discharge from the agency for one (Patient #7) of five patients. Findings: Patient #7 A review of the clinical record showed no notice of non-coverage prior to discharge from the agency on 12/31/20. On 04/22/21 at 12:15 p.m., Staff A stated there was no notice of non-coverage for Patients #7 and the patient should have received a notice prior to being discharged from the agency.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of: 1. missed home health aide visits for one (Patient #1) of seven patients; 2. missed physical therapy visits for three (Pt's #3, 4 and #5) of seven patients; 3. missed skilled nurse visits for four (Pt's #4, 5, 6 and #7) of seven patients; 4. missed medical social work visits for one (Patient #4) of seven patients and; 5. notice of patient discharge from agency services for one (Patient #7) of seven patients. Findings: Patient #1 A review of the POC dated 02/21/21 to 04/21/21 showed a home health aide frequency of two times a week for eight weeks. Documentation showed CHHA visits were missed during the weeks of 03/28/21 through 04/02/21 (one missed CHHA visit); 04/04/21 through 04/10/21 (one missed CHHA visit); and 04/18/21 through 04/21/21 (one missed CHHA visit.) Documentation showed no patient/caregiver refusal of visit, no physician notification of the missed visits and no change in orders. Patient #3 A review of the POC dated 02/16/21 to 04/16/21 showed a physical therapy frequency of one day times one day, one time a week for one week and then two times a week for one week. Documentation showed physical therapy visits were missed during the week of 03/01/21 through 03/07/21 (two missed physical therapy visits.) Documentation showed no patient/caregiver refusal of visit, no physician notification of the missed visits and no change in orders. Patient #4 A review of the POC dated 02/04/21 to 04/04/21 showed a physical therapy frequency of one day times one, two times a week times one week and then one time a week times two weeks; SN frequency of one day times one day, one time a week for one week, three times a week for one week, one time a week for three weeks, one time a week for one week and then one time a week for one week; and a medical social work frequency of one time a day for one day. Documentation showed physical therapy visits were missed during the week of 02/08/21 through 02/14/21 (two missed physical therapy visits); SN visits were missed during the week of 02/15/21 through 02/21/21 (one missed SN visits) and a medical social work visit was missed on 02/08/21 (one missed MSW visit.) Documentation showed no patient/caregiver refusal of visit, no physician notification of the missed visits and no change in orders. Patient #5 A review of the POC dated 02/07/21 to 04/07/21 showed a physical therapy frequency of one times a week times six weeks and a SN frequency of three times a week for nine weeks. Documentation showed physical therapy visits were missed during the week of 02/15/21 through 02/21/21 (one missed physical therapy visit); SN visits were missed during the week of 04/05/21 through 04/07/21 (one missed SN visits.) Documentation showed no patient/caregiver refusal of visit, no physician notification of the missed visits and no change in orders. Patient #6 A review of the POC dated 12/08/20 to 02/05/21 showed a SN frequency of two times a week for one week, and then three times a week for eight weeks. Documentation showed skilled nurse visit was missed during the week of 12/28/20 through 01/03/21 (one missed SN visits.) Documentation showed no patient/caregiver refusal of visit, no physician notification of the missed visits and no change in orders. Patient #7 1. A review of the POC dated 12/08/20 to 02/05/21 showed a SN frequency of one time a week for one week and then one time a week for one week. Documentation showed a skilled nurse visit was missed during the week of 12/21/20 through 12/27/20 (one missed SN visits.) Documentation showed no patient/caregiver refusal of visit, no physician notification of the missed visits and no change in orders and; 2. A review of the clinical record showed no documentation the physician was notified of the patient's discharge from agency services due to a change in payor source on 12/31/20. On 04/22/21 at 12:00 p.m., Staff A stated: 1. missed SN, CHHA, PT and MSW visits for Pt's #1, 3, 4, 5, 6 and #7 should have been reported to the physician and documented and; 2. the physician should have been notified of the agency discharge for Patient #7.

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 show evidence of a patient centered QAPI Program that demonstrated self-monitoring and efforts to improve care, services and operations for all patients and 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 calendar year's 2019 and 2020. On 04/22/21 at 10:30 a.m., Staff B stated there was no documentation which showed evidence of an ongoing patient centered QAPI program, which included the collection, utilization or analysis of QAPI data for calendar year's 2019 or 2020.

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 patient centered QAPI Program activities for all patients and employees. Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities, no patient record audits and no infection surveillance reports to improve the care, services, and operations of the agency for calendar year's 2019 and 2020. Documentation showed no COVID19 focused activities for calendar year 2020. On 04/22/21 at 10:30 a.m., Staff B stated they had no documentation which showed governing body oversite of QAPI program activities for calendar year's 2019 and 2020 and no COVID19 focused activities for calendar year 2020.

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 a comprehensive infection control program was conducted for all patients and employees. Findings: A review of administrative records showed no comprehensive infection control program for the agency. Additional infection control surveillance documentation was requested and yielded no further reports. On 04/22/21 at 10:30 a.m., Staff B stated: 1. the agency had no comprehensive infection surveillance program in place and; 2. no infection surveillance activities were reported through the agency's QAPI program.

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 physician notification of reported pain levels above ordered parameter for two (Pt's #3 and #6) of seven patients. Findings: Patient #3 A review of a plan of care dated 02/16/21 to 04/16/21 documented a diagnosis of heart failure with chronic kidney failure, stage 3-4 and showed a physician reporting parameter of pain greater than 7 of 10. A physical therapy note dated 02/19/21 showed a pain level of 9 of 10. Documentation showed no physician notification of the patient's pain level and no change in orders. Patient #6 A review of a plan of care dated 12/08/20 to 02/05/21 documented a diagnosis of diabetes mellitus type II with chronic kidney disease and showed a physician reporting parameter of pain greater than 7 of 10. Skilled nurse visit notes dated 01/11/21 and 01/12/21 showed a pain level of 9 of 10. Documentation showed no physician notification of the patient's pain levels and no change in orders. On 04/22/21 at 12:15 p.m., Staff B stated the physician should have been notified of the reported pain levels for Pt's #3 and #6 during the home visits.