Alpha Homehealth of Okc LLC

“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 the assessment of wounds was provided as ordered for two (Patient #6 and 11) of 13 patients. Patient #6 A review of the plan of care dated 10/17/23 to 12/15/23 showed a primary diagnosis of unspecified open wound right buttock with a skilled nurse frequency of two visits per week for two week and one visit per week for six week and orders to measure the wound weekly. A review of the clinical record showed the following: Skilled nurse assessments dated 10/17/23 and 10/20/23 for the week of 10/17/23 to 10/21/23, documented no wound measurements. Skilled nurse assessments dated 10/24/23 and 10/27/23 for the week of 10/22/23 to 10/28/23, documented no wound measurements. Skilled nurse assessments dated 10/31/23 for the week of 10/27/23 to 11/04/23, documented no wound measurements. Skilled nurse assessments dated 11/07/23 for the week of 11/05/23 to 11/11/23, documented no wound measurements. Skilled nurse assessments dated 11/14/23 for the week of 11/12/23 to 11/18/23, documented no wound measurements. Skilled nurse assessments dated 11/21/23 for the week of 11/19/23 to 11/25/23, documented no wound measurements. Skilled nurse assessments dated 11/28/23 for the week of 11/26/23 to 12/02/23, documented no wound measurements. Patient #11 A review of the plan of care dated 07/31/21 to 09/28/21 showed a primary diagnosis of venous insufficiency with a skilled nurse frequency of two visits per week for two week and one visit per week for six week and orders observe and assess skin integrity status. A review of the clinical record showed the following: Skilled nurse assessments dated 08/03/21 and 08/06/21 for the week of 08/01/21 to 08/07/21, documented no wound measurements. Skilled nurse assessments dated 08/10/21 and 08/13/21 for the week of 08/08/21 to 08/14/21, documented no wound measurements. Skilled nurse assessments dated 08/17/21 for the week of 08/15/21 to 08/21/21, documented no wound measurements. On 02/21/24 at 2:40 pm, Staff A stated: 1. the wound assessments failed to document wound measurements for Patients #6 and 11; 2. orders for wound/skin assessments were not followed for Patients #6 and 11; 3. wound measurements should have been obtained for Patients #6 and 11.”

“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 quality indicator data was used in the design of the QAPI program for all future patients and any new patients admitted to the agency. A review of QAPI records showed no use of quality indicator data in the QAPI program documentation for 2022 and 2023. On 02/21/24 at 1:30 pm, Staff A stated the QAPI program did not include the use of quality indicator data.”

“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 the plan of care was fully developed to include individualized interventions in relation to the primary diagnosis for thirteen (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13) of 13 patients reviewed. Patient #1 A review of the plan of care dated 09/25/21 to 11/23/21 showed a primary diagnosis of hypertensive heart with heart failure and showed no patient specific interventions related to the monitoring of weights, diet and methods for decreasing fluid overload. Patient #2 A review of the plan of care dated 12/21/21 to 02/18/22 showed a primary diagnosis of severe persistent asthma and showed no patient specific interventions for the management of the asthma. Patient #3 A review of the plan of care dated 11/12/21 to 01/10/22 showed a primary diagnosis of encounter for change or removal of surgical wound dressing and showed no patient specific interventions for the management of the surgical wound. Patient #4 A review of the plan of care dated 01/08/23 to 03/08/23 showed a primary diagnosis of essential hypertension and showed no patient specific interventions for the management of the hypertension. Patient #5 A review of the plan of care dated 03/18/21 to 05/16/21 showed a primary diagnosis of chronic diastolic heart failure and showed no patient specific interventions for the management of fluid overload, diet or weight monitoring. Patient #6 A review of the plan of care dated 10/17/23 to 12/15/23 showed a primary diagnosis of unspecified open wound right buttock and showed no patient specific interventions for the management of the wound. Patient #7 A review of the plan of care dated 12/20/23 to 02/17/24 showed a primary diagnosis of infection following a procedure and showed no patient specific interventions for the management of the infection. Patient #8 A review of the plan of care dated 06/02/21 to 07/31/21 showed a primary diagnosis of aftercare following surgery for neoplasm and showed no patient specific interventions for care specifically related to the removal of the neoplasm. Patient #9 A review of the plan of care dated 03/24/21 to 05/22/21 showed a primary diagnosis of unspecified dementia and showed no patient specific interventions for the management of dementia. Patient #10 A review of the plan of care dated 05/19/22 to 07/17/22 showed a primary diagnosis of noninfective gastroenteritis and colitis and showed no patient specific interventions for the management of gastroenteritis or colitis. Patient #11 A review of the plan of care dated 07/31/21 to 09/28/21 showed a primary diagnosis of venous insufficiency and showed no patient specific interventions for the management of venous insufficiency. Patient #12 A review of the plan of care dated 01/11/22 to 03/11/22 showed a primary diagnosis of aftercare following surgery neoplasm and showed no patient specific interventions for the management of the aftercare specific to the neoplasm surgery. Patient #13 A review of the plan of care dated 08/14/21 to 10/12/21 showed a primary diagnosis of encounter for attention to ileostomy and showed no patient specific interventions for the management the ileostomy. On 02/21/24 at 2:35 pm, Staff A stated there were no patient specific interventions for the primary diagnosis for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13.”