Every finding on record at A Path of Care Home Health VI, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the Agency from 05/12/26 to 05/13/26. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. A deficiency was cited as a result of the Emergency Preparedness Survey.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency contacts and resources phone list had updated contact information for all 193 patients and all employees. Findings: A review of the Emergency Preparedness Program showed a list of local, Federal and State emergency personnel with their contact information which showed a date of 05/19/23. On 05/12/26 at 3:30 p.m., Staff A stated the list was printed 05/19/23 and they were unable to provide the current list.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency from 05/12/26 to 05/13/26. An entrance conference was conducted with Staff A and B. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B Deficiencies were cited as a result of the survey. Glossary: CHHA - Certified Home Health Aide POC - Plan of Care Pt - Patient

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial start of care assessment was completed within 48 hours of referral for one (Pt #2) of eight patients. Findings: Pt #2 A review of the clinical record showed the start of care assessment was completed 07/16/24. The physician's referral was dated 07/11/24. The clinical record showed no refusal by the patient or caregiver for a start of care within 48 hours of referral, no physician's order for a delayed start of care, and no coordination note showed why the admission was completed five days after the referral. On 05/13/26 at 1:14 p.m., Staff B stated the start of care assessment was delayed.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a current POC was provided to an assisted living facility for one (Pt #6) of three patients residing in assisted living facilities. Findings: Pt #6 A review of the resident record at the assisted living facility showed no current plan of care for the certification period of 04/30/26 to 06/28/26. On 05/13/26 at 9:30 a.m., Staff #1 (assisted living facility) stated they did not receive a copy of the current plan of care.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the CHHA supervisory visits were completed for one (Pt #3) of seven patients receiving CHHA services. Findings: Pt #3 A plan of care dated 03/23/26 to 05/21/26 showed orders for CHHA services twice a week for nine weeks. Documentation showed an RN supervisor visit was completed 12/29/25. No other CHHA supervisory visits were completed through 05/12/26 (42 days since the last CHHA supervisory visit was completed). On 05/13/26 at 1:31 pm, Staff A stated there were no aide supervisory visits after 03/30/26.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/08/23 to 05/09/23. Deficiencies were cited as a result of the Emergency Preparedness program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for all patients and employees. Findings: Review of Emergency Preparedness program administrative records showed no documentation of a community-based risk assessment which addressed the agency, its patient population, and its employees. On 05/08/23 at 3:30 p.m., Staff A stated the agency’s Emergency Preparedness program administrative records showed no all hazard community-based risk assessment.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation and maintenance of processes for a coordinated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of Emergency Preparedness program administrative records showed no administrative processes in place for a coordinated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency. On 05/08/23 at 3:30 p.m. Staff A stated the agency’s Emergency Preparedness program administrative records showed no coordinated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, 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. Findings: A review of administrative records showed the Emergency Preparedness Communication did not include updated required information related to current staff contact information identified for the agency. On 05/08/23 at 3:30 p.m., Staff A stated the agency’s Emergency Preparedness program administrative records included former staff contact information and did not include updated required information related to current staff contact information.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 05/08/23 to 05/09/23. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the survey. Glossary: EP Emergency Preparedness HHA Home Health Agency POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse SOC Start of Care

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order 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. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication regimen included insulin sliding scale doses on the medication profile for one (Patient #2) of eight patients. Findings: Patient #2 A review of the plan of care dated 04/12/23 to 06/10/23 documented a principal diagnosis of Diabetes Mellitus Type I. The medication profile showed Humalog (a type of insulin) 100 unit per milliliter sliding scale but showed no sliding scale administration frequency or dose. Documentation showed no physician notification/clarification attempt or changes in orders. On 05/09/23 at 10:10 a.m., Staff A stated the medication profile for Patient #2 should have included sliding scale dose and administration frequency.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a transfer summary for one (Patient #6) of eight patients. Findings: Patient #6 A review of the clinical record showed the patient was transferred from the agency on 05/03/23 to inpatient hospital services. Documentation showed no transfer summary and no summary of care was provided to the receiving inpatient hospital service provider. On 05/09/23 at 10:16 a.m., Staff A stated the agency did not complete and provide a transfer summary for Patient #6 to the inpatient hospital service provider.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of a Plan of Care after a comprehensive (SOC) OASIS assessment for one (Patient #6) of eight patients. Findings: Patient #2 A review of the clinical record showed no documentation of physician orders for POC episode period of 04/24/23 to 06/22/23. Documentation showed no physician notification of the conducted comprehensive assessment (SOC) on 04/24/23 and documented no physician orders. On 05/09/23 at 10:16 a.m., Staff A stated: 1. Patient #2 did not have a POC for the episode period of 04/24/23 to 06/22/23; 2. Received HHA services without a POC and; 3. Was transferred from agency services to inpatient hospital services on 05/03/23.

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 an individualized patient POC included a skilled treatment intervention due date for one (Patient #1) of eight patients. Findings: Patient #1 A review of a POC dated 02/28/23 to 04/28/23, showed orders for a SN visit frequency of one time a week for nine weeks and SN to perform flush of subclavian port every 30 days. A review of clinical documentation showed no treatment due date or date last completed on the POC. Documentation showed SN visit dates on 02/28/23, 03/07/23, 03/15/23, 03/20/23, 03/27/23, 04/04/23, 04/12/23, 04/19/23 and on 04/26/23 and showed no clinical documentation of date skilled treatment last conducted. Documentation showed no patient/caregiver refusal of SN intervention, no physician notification and no change in orders. On 05/09/23 at 10:00 a.m., Staff A stated the POC for patient #1 should have included skilled treatment intervention due date or date last completed on the POC.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure multi-disciplined professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative records showed no multi-discipline professional staff participation in QAPI activities for calendar years 2021 and 2022. On 05/09/23 at 9:30 a.m., Staff A stated administrative records showed no multi-discipline professional staff participation in QAPI activities for calendar years 2021 and 2022.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. Ongoing patient centered QAPI Program activities for calendar years 2021 and 2022; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2021 and 2022; and 3. Agency program evaluations for calendar years 2021 and 2022 for all patients and employees. Findings: A review of administrative records showed no governing body over-site of ongoing patient centered QAPI Program activities; operating budget, capital expenditure plan and allocation of resources activities and agency program evaluations for calendar years 2021 and 2022. On 05/09/23 at 9:40 a.m., Staff A stated administrative records showed no governing body over-site of ongoing patient centered QAPI Program activities, operating budget, capital expenditure plan and allocation of resources activities and agency program evaluations for calendar years 2021 and 2022.