Faith Home Health

The agency failed to ensure an All Hazards Risk Assessment was developed for all patients and staff.

The agency failed to ensure a community-based drill was conducted every two years for all patients and staff.

The agency failed to provide a patient with discharge instructions for one (Pt #7) of two discharge patients.

The agency failed to ensure measurable improvement through the QAPI program was shown for all patients and staff.

The agency failed to ensure the development of a PIP for calendar years 2024 and 2025 for all patients and staff.

The agency failed to ensure the Oklahoma State Department of Health notification of: 1. A change of ownership for all patients and staff.2. A change of administrator for all patients and staff.

The agency failed to ensure governing body oversite of the QAPI program for all patients and staff.

The agency failed to retain clinical records for five years for all patients and their families.

The agency failed to provide a patient with written notice of discharge for one (Pt #7) of two discharge patients.

The agency failed to ensure discharge planning needs were addressed for one (Pt #7) of two discharge patients.

The agency failed to ensure that weight parameters were specific to the individual for one (Pt #1) of seven patients.

The agency failed to ensure the completion of clinical notes were being completed in a timely manner for five (Pt #1, 2, 3, 4, and 5) of seven patients.

The agency failed to ensure all clinical records were completed for five (Pt #1, 2, 3, 4, and 5) of seven patients.

The agency failed to ensure all aide clinical notes were completed for two (Pt #2 and 5) of seven patients.

The agency failed to ensure development of an episodic Plan of Care after a recertification OASIS assessment for one (Patient #4) of seven patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure governing body oversite of an operating budget, capital expenditure plan and agency program evaluation activities for calendar year 2021 and 1st quarter calendar year 2022 for all patients and staff.

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.

The agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff.

The agency failed to ensure emergency preparedness disaster drill / activation event conducted on 05/11/23 included staff participation for all patients and employees.

The agency failed to ensure completion of a transfer/discharge summary for two (Patient's #6 and #7) of seven patients.

The agency failed to ensure development of an episodic Plan of Care after a recertification OASIS assessment for one (Patient #4) of seven patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

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.

The agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program from 04/01/22 to 12/31/22 and 01/01/23 to 10/02/23 for all patients and employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to ensure its infection control program included surveillance monitoring and reporting and was included in QAPI program activities for all patients and staff.

The agency failed to ensure the development of home health aide care plans for two (Patients #4 and 7) of seven patients.

The agency failed to ensure governing body oversite and allocation of an operating budget, capital expenditure plan and agency program evaluation activities for calendar year 2021 and 1st quarter calendar year 2022 for all patients and staff.

The agency failed to ensure governing body appointment/designation of the alternate clinical manager/supervising RN for the agency for all patients and staff.

The agency failed to ensure patient forms for consent and acknowledgement of Patient Rights, billing, complaint and grievance processes were obtained and maintained in the patients clinical record for five (Patients #1, 2, 4, 5 and #7) of seven patients reviewed.

The agency failed to ensure a discharge oasis assessment was completed for one (Patient #5) of seven patients.

The agency failed to ensure an individualized patient POC included: 1. Wound care orders and goals related to SN intervention for wound site care and dressing changes for one (Patient #1) of seven patients; 2. Goals related to primary diagnosis and SN interventions for disease management…

The agency failed to ensure physician orders for changed wound site care was entered into the patient’s clinical record for one (Patient #7) of seven patients.

The agency failed to ensure ongoing discharge planning and coordination of care for seven (Patients #1, 2, 3, 4, 5, 6 and 7) of seven patients.

The agency failed to ensure services were provided as ordered on the POC for: 1. SN to conduct visit frequencies as ordered by the physicians for two (Patients #2 and #3) of seven patients; 2. PT to conduct visit frequencies as ordered by the physicians for one (Patients #7) of seven patients; 3.…

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.

The agency failed to ensure governing body appointment of the clinical manager and/or supervising RN for the agency for all patients and staff.

The agency failed to ensure the agency notified OSDH of its operating branch office for all patients and employees.

The agency failed to ensure a completed transfer/discharge summary was provided for two (Patients #6 and #7) of seven patients.

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The agency failed to ensure the QAPI Program collected and documented data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees of the agency in 2019 and January through October 2020. Findings: A review of administrative records…

The agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees from 2019 to January through October 2020. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the…

The agency failed to ensure: 1) The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency; and 2) The Infection Control Program was included in…

The agency failed to ensure a completed discharge summary was provided for two (Pt's #1 and #2) of two patients.