Lifespring Edmond Home Health

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.

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.

The agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to two (Patients #6 and #8) of nine patients.

The agency failed to ensure individualized patient POCs included medication administration interventions for two (Patients #2 and #3) of nine patients.

The agency failed to ensure physician notification of changes in patient care for two (Patients #2 and #3) of nine patients.

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…

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 completion of alternative training required to meet the qualifications of a Home Health Aide for one (Staff F) of five employees reviewed.

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.

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.

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

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.…

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.

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 a comprehensive infection control program was conducted for all patients and employees.

The agency failed to ensure notice of non-coverage was provided prior to discharge from the agency for one (Patient #7) of five patients.

The agency failed to ensure physician notification of reported pain levels above ordered parameter for two (Pt's #3 and #6) of seven patients.

The agency failed to ensure physician notification of clinically significant medication interactions for three (Pt #2, #4 and #6) of eight patients.

The agency failed to ensure the physician was notified of changes in a patient condition for one (Pt #8) of eight patients.