Oxford Healthcare Hh

“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 the communication plan included contact information for Federal, State, tribal, regional, and local emergency preparedness staff for all current staff and patients. Findings: A request for contact information for Federal, State, tribal, regional, and local emergency preparedness staff yielded no results. On 05/19/26 at 11:30 AM, Staff B stated there was no contact information for the emergency preparedness resources.”

“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 PIP met requirements for all patients and employees. A review of PIPs QAPI Action Plans showed no: 1. Complete date the PIP was implemented.2. Goal for the PIP.3. Phase of the PIP.4. Interventions for the PIP.5. Data to be tracked to analyze progress toward set goals. On 05/19/26 at 12:20 p.m., Staff B stated the QAPI Action Plan did not contain all necessary information.”

“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 that VS above ordered parameters were reported to the physician for one (Pt #3) of fifteen patients. Findings: Pt #3 A review of a plan of care dated 12/27/26 to 02/24/26 showed orders to notify the physician of: Pulse greater than 110 and a Systolic BP greater than 160. A nurse’s note dated 12/31/25 showed a heart rate of 120 apical and a BP of 168/88 with no physician notification of elevated heart rate or systolic BP. A nurse’s note dated 01/29/26 showed a heart rate of 115 apical and a BP of 162/88 with no physician notification of elevated heart rate or systolic BP. On 5/19/26 at 1:27 p.m., Staff A stated there was no physician notification of the vital signs outside of parameters.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an ordered discipline evaluation was completed for one (Pt #1) of fifteen patients. Findings: Pt #1 A review of a plan of care dated 11/07/25 to 01/05/26 had an order written 11/07/26 for Occupational Therapy to evaluate the week of 11/09/26. Documentation showed no Occupational Therapy evaluation the week of 11/09/22, no patient refusal, no physician’s order to discontinue the evaluation, and no missed visit. On 05/19/26 at 1:22 p.m., Staff A stated there is no Occupational Therapy evaluation.”