Northeastern Health System Sequoyah

The agency failed to ensure evidence of a patient centered QAPI Program in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees.

The agency failed to ensure governing body oversite of the agency for program evaluation, operating budget, and capital expenditure plan in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure an Emergency Preparedness Communication Plan included current employee contact information for the agency for nine (Patients #1, 2, 3, 4, 5, 6, 7, 8 and #9) of nine patients and seven employees.

The agency failed to ensure evidence of a patient centered QAPI Program in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees.

The agency failed to ensure utilization of QAPI quality indicator data in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees.

The agency failed to ensure conduction of patient centered QAPI program activities included self-monitoring efforts that identified and evaluated outcomes to improve care, services, and operations in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees.

The agency failed to ensure performance improvement projects for the agency in calendar years 2023 and 2024 for all patients and three employees.

The agency failed to ensure governing body oversite of conduction of a patient centered QAPI program in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure infection control program surveillance data was included in QAPI program activities in calendar years 2023, 2024 and 01/01/25 to 06/24/25 for all patients and employees.

The agency failed to ensure a home health aide care plan was reviewed and updated for the certification period for three (Patients #3, 5 and #9) of nine patients.

The agency failed to ensure governing body oversite of the agency for program evaluation, operating budget, and capital expenditure plan in calendar years 2023 and 2024 for all patients and employees.

The agency failed to ensure governing body appointment of a supervising nurse for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25 for all patients and employees.

The agency failed to ensure the administrator’s name and contact information was a part of the admission packet information provided at a patient’s SOC for nine (Patients #1, 2, 3, 4, 5, 6, 7, 8, and #9) of nine patients.

The agency failed to ensure: 1. Attempted resolution of non-compliance and refusal of care for two (Patients #6 and #8) of nine patients.

The agency failed to ensure advance beneficiary notices prior to discharge from agency services were provided to two (Patients #6 and 8) of nine patients.

The agency failed to ensure individualized patient POC included: Removal of outdated PT evaluation and treatment orders were removed for one (Patient #1) of nine patients.SN interventions and goals for two (Patients #3 and #9) of nine patients.An individualized patient POC for two (Patients #4 and…

The agency failed to ensure physician orders were a part of the patient’s plan of care for one (Patient #3) of nine patients.

The agency failed to ensure: 1. SN reported the patient’s pain level outside of reporting parameters every visit as ordered for one (Patients #1) 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 certified home health aide supervisory visits were completed every 14 days in the patients’ home for one (Patient #9) of nine patients.

The agency failed to ensure governing body appointment of the administrator for the agency in calendar years 2023 and 2024 and 01/01/25 to 06/24/25 for all patients and staff.

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

The RN failed to develop a HHA POC with specific instructions determined by patient care needs for one (#1) of four (#1, #2, #5 and #7) records reviewed with orders for home health aide services.

The agency failed to ensure SN staff conducted a review of all medications to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for one…

The agency failed to ensure the RN conducted onsite Supervisory Aide Visits at least every 14 days for one (#1) of four (#1, #2, #5 and #7) patients records reviewed with orders for Home Health Aide (HHA) services.

The Governing Body failed to appoint the current Administrator for Home Health Agency.

The Governing Body failed to authorize a qualified, pre-designated person in writing to assume the same responsibilities and obligations when the Administrator is not available.