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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/04/24 to 06/06/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 06/04/24 to 06/06/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A. Deficiencies were cited as a result of the re-certification survey. Glossary: Pts Patients POC Plan of Care SN Skilled Nurse/Nursing PT Physical Therapy QAPI Quality Assessment and Performance Improvement

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: 1. SN frequencies were followed as ordered for one (Patients #2) of seven patients; 2. PT frequencies were followed as ordered for two (Patients #4 and 7) of seven patients; and 3. SN provided assessments as ordered for two (Patients #3 and 4) of seven patients. 1. Patient #2 A review of the POC dated 02/09/24 to 04/08/24 showed a SN frequency of one visit per week for eight weeks, effective 02/11/24. A review of the medical record showed the following: A SN missed visit dated 02/23/24 which documented the reason as door was locked and no answer, and no other visits made for the week of 02/18/24 to 02/24/24. A SN missed visit dated 03/28/24 which documented the reason as no answer at door and its locked, and no other visits made for the week of 03/24/24 to 03/30/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 2. Patient #4 A review of the POC dated 02/17/24 to 04/16/24 showed a PT frequency of one visit per week for one week. A further review of a physician’s order dated 02/19/24 showed a PT frequency of two visits per week for three weeks and one visit per week for five weeks. A review of a PT missed visit dated 02/20/24 documented the reason as patient was not at assisted living today, and no other visits made for the week of 02/18/24 to 02/24/24 (one of two visits). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #7 A review of the physician’s order dated 04/04/24 showed a PT frequency of one visit per week for one week, two visits per week for three weeks, and one visit per week for five weeks, effective 04/04/24. A review of a PT missed visit dated 05/07/24 documented the reason as no answer to door or phone, and no other visits made for the week of 05/05/24 to 05/11/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 3. Patient #3 A review of the POC dated 02/23/24 to 04/22/24 showed an order for SN to assess for spasticity and spasms every visit using a modified scoring tool. A review of the medical records showed no assessments were made for spasticity and spasms using a modified scoring tool during SN visits. Documentation showed no refusal of services from the patient or caregiver and no physician order for a change in services. Patient #4 A review of the POC dated 02/17/24 to 04/16/24 showed an order for SN to assess for spasticity and spasms every visit using a modified scoring tool. A review of the medical records showed no assessments were made for spasticity and spasms using a modified scoring tool during SN visits. Documentation showed no refusal of services from the patient or caregiver and no physician order for a change in services. On 06/06/24 at 11:05 a.m., Staff A stated: 1. the SN frequencies for Patient #2 were not met as ordered by the physician; 2. the PT frequencies for Patients #4 and 7 were not met as ordered by the physician; and 3. the assessments for Patients #3 and 4 were not completed as ordered by the physician.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 25 patients and all employees. A review of QAPI records showed no initiation, review, data analysis, or status of PIPs in calendar year 2023 or 01/01/24 to 06/06/24. On 06/06/24 at 11:40 a.m., Staff A stated the agency had no documentation which showed PIP activities for 2023 or 01/01/24 to 06/06/24.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body written designation of an administrator for 25 clients and all staff. Administrative records which showed governing body written designation of the administrator for the agency was requested. No documentation was provided. On 06/06/24 at 11:45 a.m., Staff A stated there was no governing body administrative records which showed written designation of the administrator for the agency.