McAlester Regional Health Center Home Health

The agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) that identified a date the assessment was developed and implemented and/or was review for all patients and employees.

The agency failed to ensure an Emergency Preparedness Communication Plan for the agency included current employee contact information 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 05/12/23 to 12/31/23 and documentation showed no after-action summary reporting for events on 02/19/24 and 08/08/24 for all patients…

The agency failed to ensure a transfer/discharge summary was completed for one (Patient #6) of eight patients.

The agency failed to show utilization and analysis of quality indicator data in its QAPI program to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through its QAPI Program in calendar year 2022, and 01/01/24 to 10/02/24 for all patients and employees.

The agency failed to ensure the Infection Control Program surveillance data was included in QAPI program activities for all patients and employees.

The agency failed to ensure governing body oversite of: 1. QAPI program activities for calendar years 2022, 2023 and 01/01/24 to 10/02/24 and; 2. Agency program evaluation for calendar years 2022, 2023 and for 01/01/24 to 10/02/24 for all patients and employees.

The agency failed to ensure individualized patient POC included: 1. SN catheter treatment/interventions or last changed/treatment due date related to suprapubic urinary catheter management for one (Patient #3) of eight patients; 2. SN intervention for venipuncture/lab draw with last competed or…

The agency failed to ensure care was coordinated between the agency and physician for one (Patient #6) of eight 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 a transfer summary was provided to the receiving service provider for one (Patient #5) of eight patients.

The agency failed to ensure occupational therapy services were available for two (Patient's #4 and #6) of 10 patients.

The agency failed to ensure evidence of a patient centered QAPI Program for 79 patients and all employees for calendar year 2019. 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…

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 79 patients and all employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for 79 patients and all employees.

The agency failed to ensure required documentation and review of designated PIP's through their QAPI Program for 79 patients and all employees.

The agency failed to ensure governing body oversite of patient centered QAPI Program activities for 79 patients and all employees.

The agency failed to ensure governing body oversite of: 1. agency program evaluation and; 2. an operating budget and allocation of resources activities for calendar year's 2019, 2020 and 01/01/21 to 08/04/21 effecting 79 patients and all staff.

The agency failed to ensure a medication profile was reviewed and updated with an ordered medication for one (Patient #1) of 10 patients.

The agency failed to ensure a physical therapy discharge assessment was conducted by a Physical Therapist for one (Patient #4) of 10 patients.

The agency failed to ensure a completed discharge summary was provided for one (Patient #10) of 10 patients.