Every finding on record at Advantage Home Health and Hospice LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/21/21. 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 12/21/21. 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 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 re-certification survey.

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 development of an individualized plan of care for one (Patient #2) of seven patients. A review of the plan of care dated 09/23/21 to 11/21/21 showed a primary diagnosis of hypertensive heart with heart failure and documented a skilled nurse frequency of one visit per week for eight weeks. The plan of care documented no interventions to monitor or weight patient in relation to the primary disease process. A review of the electronic medical record showed the following: A skilled nurse assessment dated 09/28/21 documented no patient weight. A skilled nurse assessment dated 10/05/21 documented no patient weight. A skilled nurse assessment dated 10/08/21 documented no patient weight. A skilled nurse assessment dated 10/11/21 documented no patient weight. A skilled nurse assessment dated 10/21/21 documented no patient weight. A skilled nurse assessment dated 10/26/21 documented no patient weight. A skilled nurse assessment dated 11/04/21 documented no patient weight. A skilled nurse assessment dated 11/09/21 documented no patient weight. A skilled nurse assessment dated 11/18/21 documented no patient weight. No weight was obtained, nor any means of monitoring weight gain or weight loss was obtained in relation to the primary diagnosis throughout this this certification period. On 12/21/21 at 3:20 pm., Staff B stated the plan of care should have documented the monitoring of weight gain or weight loss in relation to the primary diagnosis.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for all 21 patients and staff. A review of administrative records showed no ongoing infection control surveillance data for calendar year's 2019, 2020 and from January 01, 2021 to December 21, 2021. On 12/21/21 at 4:00 pm, Staff A stated the agency had no comprehensive infection surveillance program in place.