Every finding on record at Amedisys Oklahoma, L L C

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 06/10/25 to 06/12/25. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the required number of emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted from 01/01/24 to 12/31/24 for 1447 patients and 71 employees. Findings: A review of emergency preparedness records showed a disaster activation on 05/19/24 and showed no other table-top exercise, drill, community drill or plan activation event from 01/01/24 to 12/31/24. On 06/11/25 at 1:00 p.m. Staff A stated there was no other table-top exercise, drill, community drill or plan activation event from 01/01/24 to 12/31/24.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency from 06/10/25 to 06/12/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as a contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D, E, F and G. Standard level deficiencies were cited as a result of the survey. Glossary: mmhg millimeters of mercury NPWT negative pressure wound treatment OASIS outcome assessment [system] information set OT occupational therapy PT physical therapy POC Plan of Care SN skilled nurse SOC start of care

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 a SOC and/or initial assessment was conducted within 48 hours of referral for nine (Patients #1, 4, 8, 10, 14, 15, 16, 17 and #18) of 20 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 10/28/24 and the SOC/initial assessment occurred on 12/18/24. Documentation showed no patient refusal of SOC/initial assessment, no physician notification of a delay in SOC/initial and no change in orders. On 06/12/25 at 9:45 a.m., Staff A stated the SOC/initial assessment should have been conducted by 10/30/24 and any delay in the SOC/initial assessment should have been documented in the clinical record. Patient #4 A review of the clinical record showed the agency received referral information on 03/20/25 and the SOC/initial assessment occurred on 03/25/25. A communication entry dated 04/07/25 the SOC was requested by the patient on 03/25/25. Documentation showed no patient refusal of SOC/initial assessment prior to 04/07/25, no physician notification of a delay in SOC and no change in orders. On 06/12/25 at 9:57 a.m., Staff A stated the SOC/initial assessment should have been conducted by 03/22/24 and any delay in the SOC/initial assessment should have been documented in the clinical record. Patient #8 A review of the clinical record showed the agency received referral information on 04/15/25 and the SOC/initial assessment occurred on 04/20/25. Documentation showed no patient refusal of SOC/initial assessment, no physician notification of a delay in SOC and no change in orders. On 06/12/25 at 10:10 a.m., Staff A stated: 1. The SOC/initial assessment should have been conducted by 04/17/24 and any delay in the SOC/initial assessment should have been documented in the clinical record. 2. The nurse attempted to do the SOC/initial before 04/20/25 but the patient wanted to wait until her daughter was present. 3. The delay in the SOC/initial was not documented in the clinical record. Patient #10 A review of the clinical record showed the agency received referral information on 05/09/25 and the SOC/initial assessment occurred on 05/12/25. A communication entry dated 05/13/25 documented the patient was back in the hospital which delayed the SOC/initial. Documentation showed no patient rehospitalization from 05/09/25 to 05/12/25, no physician notification of a delay in SOC/initial and no change in orders. On 06/12/25 at 9:57 a.m., Staff A stated the SOC/initial assessment should have been conducted by 05/11/24 and any delay in the SOC/initial assessment should have been documented in the clinical record prior to the SOC/initial. Patient #14 A review of the clinical record showed the agency received referral information on 05/30/25 and the SOC/initial assessment occurred on 06/04/25. Documentation showed no patient/caregiver refusal of the SOC/initial, no physician notification of a delay in SOC/initial and no change in orders. On 06/12/25 at 10:37 a.m., Staff A stated: 1. The SOC/initial assessment should have been conducted by 06/01/24 and any delay in the SOC/initial assessment should have been documented in the clinical record prior to the SOC/initial. 2. I think the patient remained in the inpatient facility until 06/03/25 but there is no documentation of that in the clinical record. Patient #15 A review of the clinical record showed the agency received referral information on 04/17/25 and the SOC/initial assessment occurred on 04/21/25. A communication entry dated 04/25/25 stated the SOC/initial was requested by the patient on 04/21/25. Documentation showed no patient refusal of SOC/initial assessment prior to 04/21/25, no physician notification of a delay in SOC/initial and no change in orders. On 06/12/25 at 10:40 a.m., Staff A stated the SOC/initial assessment should have been conducted by 04/19/24 and any delay in the SOC/initial assessment should have been documented in the clinical record. Patient #17 A review of the clinical record showed the agency received referral information on 03/17/25 and the SOC/initial assessment occurred on 03/22/25. A communication entry dated 03/28/25 stated the SOC/initial was requested by the patient on 03/22/25. Documentation showed no patient refusal of SOC/initial assessment prior to 03/28/25, no physician notification of a delay in SOC/initial and no change in orders. On 06/12/25 at 10:52 a.m., Staff A stated the SOC/initial assessment should have been conducted by 03/19/24 and any delay in the SOC/initial assessment should have been documented in the clinical record. Patient #18 A review of the clinical record showed the agency received referral information on 05/23/25 and the SOC/initial assessment occurred on 05/28/25. Documentation showed no patient refusal of SOC/initial assessment, no physician notification of a delay in SOC/initial and no change in orders. On 06/12/25 at 10:55 a.m., Staff A stated the SOC/initial assessment should have been conducted by 05/25/24 and any delay in the SOC/initial assessment should have been documented in the clinical record.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge OASIS assessment was completed for one (Patient #18) of 20 patients. Findings: Patient #18 A review of the clinical record showed a start of care date of 05/28/25. Documentation showed a physician’s order dated 06/03/25 for discharge from agency services by patient request. Documentation showed no discharge from agency services; no discharge OASIS assessment, and no change in orders. On 06/12/25 at 10:55 a.m., Staff A stated: 1. The patient only had the SOC visit. 2. Patient #18 did not need a discharge visit or OASIS assessment. 3. No discharge OASIS was completed. 4. The SOC OASIS was not backed out of the system as a non-admission.

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 the individualized POC included SN catheter interventions due date or last changed treatment date for urinary catheter management for one (Patient #1) of 20 patients. Findings: Patient #1 A review of the POC dated 04/17/25 to 06/15/25 showed orders for SN: 1. Visit frequency of one time a week for one week, one time every four weeks for four weeks, then one time every two weeks for two weeks. 2. Conduct assessment, monitoring, intervention and teaching of patient health conditions every visit. 3. SN to conduct foley catheter 16 French/30 cubic centimeters catheter change every month. SN visit documentation showed SN visits were conducted on 04/29/25 and on 05/26/25 and showed no foley catheter intervention last changed or monthly change due date and no physician notifications and no change in orders. On 06/12/25 at 9:45 a.m., Staff A stated the POC should have included foley catheter intervention last changed or monthly change due date for patient #1.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were a part of the patient’s POC for one (Patient #8) of 20 patients. Findings: Patient #8 A review of the POC dated 04/20/25 to 06/18/25 showed orders for SN to conduct wound site care to left foot each visit. The wound care order stated: SN to irrigate/cleanse site with VASHE or Dakin’s solution, pat dry, apply skin prep to peri-wound, apply NPWT at 150 mmhg every three days and as needed. SN visit notes dated 04/23/25 and 04/25/25 showed no application of NPWT during conducted wound care. The SN visit notes showed no physician notification, coordination of care communications and no written order to place the application of the negative pressure wound treatment on hold. On 06/12/25 at 10:10 a.m., Staff A stated there were no orders to hold the application of the negative pressure wound treatment on hold.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for seven (Patients #1, 2, 3, 5, 7, 9 and #10) of 20 patients. Patient #1 A review of the POC dated 04/17/25 to 06/15/25 showed orders for a PT visit frequency and duration of one time a week for eight weeks. During the week of 05/04/25 to 05/10/25 a PT visit note showed a PT visit was missed on 05/09/25 (Friday). The PT visit note showed: 1. No attempts to reschedule the visit. 2. A fax notification to the physician on 05/13/25 (4 days from the missed visit date). 3. No follow up physician communications or coordination of care notes. On 06/12/25 at 9:45 a.m., Staff A stated the PT should have: 1. Attempted to reschedule the PT visit. 2. Notified the physician’s office the day of the missed visit. Patient #2 A review of the POC dated 03/28/25 to 05/26/25 showed orders for a PT visit frequency and duration of one time a week for eight weeks. During the week of 05/27/25 to 05/31/25 a PT visit note showed: 1. A PT visit was missed on 05/29/25 (Thursday). 2. No documentation the physician was notified of the missed visit. During the week of 06/01/25 to 06/07/25 a PT visit note showed: 1. A PT visit was missed on 06/05/25 (Thursday). 2. No attempts to reschedule the visits, showed a fax notification to the physician on 06/08/25 (3 days from the missed visit date). 3. No follow up physician communications or coordination of care notes. On 06/12/25 at 9:55 a.m., Staff A stated the PT should have: 1. Attempted to reschedule the PT visits. 2. Notified the physician’s office the day of the missed visits. Patient #3 A review of the POC dated 04/23/25 to 06/21/25 showed orders for a SN visit frequency and duration of two times a week for two weeks, one time a week for one week, then two times a week for six weeks. During the week of 05/18/25 to 05/24/25 a SN visit note showed: 1. A SN visit was missed on 05/23/25 (Friday). 2. A fax notification to the physician on 05/29/25 (6 days after the missed visit date). 3. No attempts to reschedule the visit and showed no follow up physician communications or coordination of care notes. On 06/12/25 at 9:55 a.m., Staff A stated the SN should have: 1. Attempted to reschedule the SN visit. 2. Notified the physician’s office the day of the missed visits. Patient #5 A review of the POC dated 05/08/25 to 07/21/25 showed orders for a PT visit frequency and duration of one time a week for four weeks, two times a week for one week, then once a week for four weeks. During the week of 05/11/25 to 05/17/25 a PT visit note showed: 1. A PT visit was missed on 05/16/25 (Friday). 2. A fax notification to the physician on 05/20/25 (4 days from the missed visit date). During the week of 05/25/25 to 05/31/25 a PT visit note showed: 1. A PT visit was missed on 06/30/25 (Friday). 2. A fax notification to the physician on 06/04/25 (6 days from the missed visit date). 3. No attempts to reschedule the visits and showed no follow up physician communications or coordination of care notes. On 06/12/25 at 10:00 a.m., Staff A stated the PT should have: 1. Attempted to reschedule the PT visits. 2. Notified the physician’s office the day of the missed visits. Patient #7 A review of the POC dated 03/27/25 to 05/25/25 showed orders for a PT visit frequency and duration of one time a week for one week, two times a week for four weeks, then one time a week for three weeks. During the week of 04/06/25 to 04/12/25 a PT visit note showed: 1. A PT visit was missed on 04/12/25 (Saturday). 2. The physician was notified of the missed visit. During the week of 04/13/25 to 04/19/25 a PT visit note showed: 1. A PT visit was missed on 04/15/25 (Tuesday). 2. The physician was notified of the missed visit. During the week of 04/20/25 to 04/26/25 a PT visit note showed: 1. A PT visit was missed on 04/25/25 (Friday). 2. No documentation the physician was notified of the missed visit. The POC showed orders for a SN visit frequency and duration of one time a week for nine weeks. During the week of 04/27/25 to 05/03/25 A SN visit note showed: 1. A SN visit was missed on 04/29/25 (Tuesday). 2. No documentation the physician was notified of the missed visit. 3. No attempts to reschedule the visits. 4. No follow up physician communications or coordination of care notes. On 06/12/25 at 10:05 a.m., Staff A stated the PT and SN should have: 1. Attempted to reschedule the missed visits. 2. Notified the physician’s office the day of the missed visits. Patient #9 A review of the POC dated 04/20/25 to 06/18/25 showed orders for a PT visit frequency and duration of one time a week for seven weeks. During the week of 04/23/25 to 04/26/25 a PT visit note showed: 1. A PT visit was missed on 04/25/25 (Friday). 2. A fax notification to the physician on 04/29/25 (4 days after the missed visit date). No attempts to reschedule the visit. 3. No follow up physician communications or coordination of care notes. On 06/12/25 at 10:16 a.m., Staff A stated the PT should have: 1. Attempted to reschedule the PT visit. 2. Notified the physician’s office the day of the missed visits. Patient #10 A review of the POC dated 05/12/25 to 07/10/25 showed orders for a PT visit frequency and duration of two times a week for two weeks, then one time a week for seven weeks. During the week of 05/25/25 to 05/31/25 a PT visit note showed: 1. A PT visit was missed on 05/30/25 (Friday). 2. A fax notification to the physician on 06/04/25 (5 days from the missed visit date). No attempts to reschedule the visit. 3. No follow up physician communications or coordination of care notes. On 06/12/25 at 10:19 a.m., Staff A stated the PT should have: 1. Attempted to reschedule the PT visit. 2. Notified the physician’s office the day of the missed visits.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. PT conducted visits as ordered for three (Patients #4, 13 and #15) of 20 patients. 2. SN monitored the patient’s pain level and reported levels outside of reporting parameters every visit as ordered for two (Patients #5 and #9) of 20 patients. 3. SN monitored a patient’s blood sugar every visit as ordered for one (Patient #7) of 20 patients. 4. SN conducted visits as ordered for three (Patients #7, 17 and #20) of 20 patients. 5. PT conducted telehealth visit as ordered for one (Patient #10) of 20 patients. 6. SN monitored a patient’s heart rate every visit and reported levels outside of reporting parameters as ordered for one (Patient #15) of 20 patients. Findings: Patient #4 A review of the POC dated 03/25/25 to 05/23/25 showed orders for PT to treat with a frequency and duration of one time a week for two weeks, two times a week for three weeks, one time a week for four weeks, then one time a week for four weeks. During the week of 04/06/25 to 04/12/25 a PT visit note showed: 1. A missed visit dated 04/08/25. 2. A visit conducted on 04/11/25 (two visits ordered, one visit conducted). 3. No attempts to reschedule the missed visit, no physician notification and no changes in orders. On 06/12/25 at 9:57 a.m., Staff A stated the PT visits should have been conducted as ordered on the POC. Patient #5 A review of the POC dated 05/08/25 to 07/06/25 showed orders for PT and OT to monitor the patient’s pain level every visit and report pain levels outside of the reported pain parameters of greater than 7 of 10. During a PT visit dated 06/03/25 the patient reported a pain level of 8 of 10. The PT visit note showed no physician notification and no changes in orders. On 06/12/25 at 10:00 a.m., Staff A stated the PT should have reported the patient’s pain level as ordered on the POC at the time of the visit. Patient #7 A review of the POC dated 03/27/25 to 05/25/25 showed orders for SN visit frequency and duration of one time a week for nine weeks to monitor the patient’s blood sugar every visit and report blood sugar levels outside of the reported blood sugar parameters of less than less than 70 and greater than 350. SN visit notes dated 04/01/25, 04/10/25, 04/15/25 and on 04/22/25 showed: 1. No blood sugar monitoring was conducted. 2. No patient/caregiver refusal of blood sugar monitoring, no physician notifications and no changes in orders. During the week of 04/27/25 to 05/03/25 a SN visit note showed: 1. A missed SN visit on 04/29/25, Tuesday (one visit ordered, no visit conducted). 2. No attempt to reschedule the SN visit. 3. No physician notification and no changes in orders. On 06/12/25 at 10:05 a.m., Staff A stated: 1. The SN should have attempted to reschedule the SN visit. 2. The SN should have monitored the patient’s blood glucose level every visit as ordered on the POC. Patient #9 A review of the POC dated 04/23/25 to 06/21/25 showed orders for PT to monitor the patient’s pain level every visit and report pain level outside of the reported pain parameters of greater than 7 of 10. During a PT visit dated 06/06/25 the patient reported a pain level of 8 of 10. The PT visit note showed: 1. A fax notification to the physician on 06/09/25 (3 days from the date of the visit). 2. No follow up physician notification and no changes in orders. On 06/12/25 at 10:16 a.m., Staff A stated the PT should have reported the patient’s pain level as ordered on the POC at the time of the visit. Patient #10 A review of the POC dated 05/12/25 to 07/10/25 showed orders for PT to conduct a telehealth visit during the week of 05/12/25. Clinical record documentation showed no telehealth visit was conducted during the week of 05/12/25 (one telehealth visit ordered, no telehealth visit conducted) and showed no physician notification and no changes in orders. On 06/12/25 at 10:19 a.m., Staff A stated the PT telehealth visit should have been conducted as ordered on the POC. Patient #13 A review of the POC dated 05/15/25 to 07/13/25 showed orders for PT to treat with a frequency and duration of one visit every two weeks times two weeks, one time a week for one week, two times a week for three weeks, then one time a week for two weeks. During the week of 05/25/25 to 05/31/25 a PT visit note showed a visit conducted on 05/27/25 (no visits ordered, one visit conducted). The PT visit note showed no physician notification and no changes in orders. On 06/12/25 at 10:37 a.m., Staff A stated the PT visits should have been conducted as ordered on the POC. Patient #15 A review of the POC dated 04/21/25 to 06/19/25 showed orders for SN one time a week for eight weeks to assess and instruct the patient’s heart rate every visit and report levels outside of reporting parameters of less than 60 beats per minute. A SN visit note dated 06/02/25 showed: 1. A heart rate of 58 beats per minute. 2. No showed physician notification by fax on 06/04/25 (two days after the date of the visit). 3. No changes in orders. The POC showed orders for PT to treat with a frequency and duration of one visit every two weeks times two weeks, two times a week for one week, then one time a week for five weeks. During the week of 05/04/25 to 05/10/25 a PT visit note showed: 1. A visit conducted on 05/09/25 (no visits ordered, one visit conducted). 2. No physician notification and no changes in orders. On 06/12/25 at 10:40 a.m., Staff A stated: 1. The SN should have reported the heart rate to the physician’s office as ordered on the POC. 2. The PT visits should have been conducted as ordered on the POC. Patient #17 A review of the POC dated 03/22/25 to 05/20/25 showed orders for SN visits frequency and duration of one time a week for nine weeks. During the week of 03/23/25 to 03/29/25 the clinical record documentation showed: 1. A missed visit dated 03/25/25 (Tuesday). 2. A visit conducted on 04/11/25 (two visits ordered, one visit conducted). 3. No attempts to reschedule the missed visit. 4. A fax physician notification on 04/10/25 (16 days from the date of the missed visit). 5. No changes in orders. On 06/12/25 at 9:57 a.m., Staff A stated: 1. The SN visits should have been conducted as ordered on the POC. 2. The missed visit should have been rescheduled during that week. 3. The physician should have been notified of the missed visit when it occurred. Patient #20 A review of the POC dated 04/10/25 to 06/08/25 showed orders for a SN visit frequency and duration of one time a week for nine weeks. During the week of 04/20/25 to 04/26/25 A SN visit note showed: No visit was conducted (one visit ordered, no visit conducted). 1. No patient/caregiver refusal of a visit. 2. No physician notification and no changes in orders. On 06/12/25 at 9:57 a.m., Staff A stated the SN visit should have been conducted as ordered on the POC.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit notes were completed for one (Patient # 11) of 20 patients. Findings: Patient #11 A review of the POC dated 05/20/24 to 07/18/25 showed orders for SN to perform wound care interventions to the right calf and the right shin each visit. A SN visit note dated 06/02/25 showed no wound site interventions were performed to the right calf site during the visit. On 06/12/25 at 10:25 a.m., Staff A stated the SN clinical visit note: 1. On 06/02/25 showed a wound site assessment of the right calf. 2. Did not show if wound site interventions were performed to the right calf.

Emergency Prep The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 07/25/22 to 07/27/22. 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 07/25/22 through 07/27/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and Staff C were identified as the contact persons for administrative issues and Staff A and Staff B were identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff A and C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: HHA Home Health Agency Mg milligram POC Plan of Care SN Skilled Nurse

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: Show documentation of the problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services for one (Patient #15) of 17 patients;Educate the patient on potential health outcomes from discontinued HHA care and services for one (Patient #15) of 17 patients;Notify the physician of the patient's behaviors that impeded the HHA from providing care and services for one (Patient #15) of 17 patients and;Inform the physician of the patient’s imminent discharge from the HHA for cause for one (Patient #15) of 17 patients. Findings: Patient #15 A review of a plan of care for 05/07/22 to 07/05/22 showed a SN visit frequency of one time a week for eight weeks for SN to assess and teach medication management and effectiveness; assess and teach intervention for disease management of altered genitourinary status, anemia, cardiovascular status and heart failure, to include signs of decompensation and intervention to minimize severity of fluid overload. A review of SN visit notes dated 05/27/22 and 06/03/22 documented patient continued alcohol use. Documentation showed no identified problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services, no communication or education attempts to the patient for potential health outcomes resulting from discontinued HHA care and services, no physician notification of the patient's behaviors that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 07/01/22. On 07/27/22 at 11:40 a.m., Staff A stated there was no documentation of: Problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services;Patient education of potential health outcomes from discontinued HHA care and services;Physician notification of the patient's behaviors that impeded the HHA from providing care and services and;Physician notification of the patient’s imminent discharge from the HHA for cause.

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 profile was reviewed and updated with ordered medications for two (Patients #4 and #12) of 17 patients. Findings: Patient #4 A review of a POC dated 06/24/22 to 08/22/22 showed an order dated 06/28/22 for ciprofloxin (an antibiotic) 500 mg once daily times seven days. Further review of clinical documentation showed no update and review of the medication ciprofloxin on the medication profile. Patient #12 A review of a POC dated 05/14/22 to 07/12/22 showed the medication amoxicillian / clavunated potassium (an antibiotic) 875/125 mg twice daily dated 04/13/22. Continued review of clinical documentation showed no end date to the medication and no update and review of the medication on the medication profile during the recertification process for continued HHA services on the subsequent POC. On 07/27/22 at 10:50 a.m., Staff A stated the medication profiles should have been updated and reviewed for: The addition of the medication for Patient #4 and;The dose end date for the medication on Patient #12.

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 the individualized patient POC included recurring urinary catheter change treatment due dates for two (Patients #4 and #6) of 17 patients. Findings: Patient #4 A review of the plan of care dated 06/24/22 to 08/22/22 documented a principal diagnosis of pressure ulcer to the sacral region. POC orders directed SN to change indwelling Foley catheter every month. POC documentation showed no treatment date the indwelling Foley catheter change was due. Patient #6 A review of the plan of care dated 07/01/22 to 08/29/22 documented a principal diagnoses of Diabetes Mellitus Type II and spinal stenosis. POC orders directed SN to change indwelling Foley catheter every four weeks. POC documentation showed no treatment date the indwelling Foley catheter change was due. On 07/27/22 at 10:52 a.m., Staff A stated recurring urinary catheter change due dates should have been documented in the POCs for Patients #4 and #6.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for two (Patients #1 and #9) of 17 patients. Findings: Patient #1 A review of a plan of care dated 06/07/22 to 08/05/22 documented a primary diagnosis of stage II pressure ulcer to the right buttock. Documentation showed SN to instruct diabetic care and monitor, record and report patient blood sugar of less than 70 and greater than 250. Documentation showed no patient blood sugar readings on SN visit notes dated 06/10/22, 06/13/22, 06/17/22, 06/20/22, 06/24/22, 06/27/22, 07/01/22, 07/05/22, 07/08/22, 07/11/22, 07/15/22, 07/18/22 and on 07/22/22. SN visit notes on 06/24/22 and on 07/22/22 documented the patient stated he did not do monitoring of blood sugar levels. Documentation showed no physician coordination of care communications that the patient declined to monitor blood sugar levels and no changes in orders. Patient #9 A review of a plan of care dated 06/02/22 to 07/31/22 documented a primary diagnosis of stage four pressure ulcer. Documentation showed a SN visit frequency of one time a week for eight weeks to assess the wound site and to conduct wound treatment: cleanse the wound with normal saline, apply Purachol ag (a wound care material), and cover with Opticel (a wound care material) and foam dressing materials. Documentation showed the patient declined the foam dressing materials during the wound care treatments during SN visits dated 06/09/22, 06/15/22, 06/29/22, 07/07/22, 07/14/22 and on 07/21/22. Documentation showed no physician coordination of care communications that the patient declined the use of the dressing material and no changes in orders. On 07/27/22 at 11:05 a.m., Staff A stated: The physician for Patient #1 should have been informed the patient declined to monitor blood glucose levels and;The physician for Patient #9 declined the use of the ordered wound site dressing material.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the POC’s: SN to conduct assessment of patient weight monitor, record and report to the physician of change in patient weight outside of reporting parameters for two (Patients #1 and #5) of 17 patients;SN to conduct assessment of patient blood sugar and monitor, record and report to the physician blood sugar levels outside of reporting parameters for four (Patients #1, 2, 5 and #7) of 17 patients and;SN to conduct assessment of patient wound site for signs and symptoms of infection for one (Patient #7) of 17 patients. Findings: Patient #1 A review of a plan of care dated 06/07/22 to 08/05/22 documented a primary diagnosis of stage II pressure ulcer to the right buttock. Documentation showed SN to instruct diabetic care and monitor, record and report patient blood sugar of less than 70 and greater than 250 and SN to perform blood sugar testing as needed; and to monitor/record patient reported weight and report to physician weight gain of two pounds in one day or five or more pounds in a week. Documentation showed no patient blood sugar readings on SN visit notes dated 06/10/22, 06/13/22, 06/17/22, 06/20/22, 06/24/22, 06/27/22, 07/01/22, 07/05/22, 07/08/22, 07/11/22, 07/15/22, 07/18/22 and on 07/22/22 and no patient weight assessment on 06/10/22, 06/13/22, 06/17/22, 06/20/22 and on 07/18/22. Documentation showed no patient/caregiver refusal of patient blood sugar or weight assessment, no physician notification of declined blood sugar monitoring and weight assessment and no change in orders. Patient #2 A review of a plan of care dated 06/06/22 to 08/04/22 documented a primary diagnosis of Diabetes mellitus Type II. Documentation showed SN to instruct diabetic care and monitor, record and report patient blood sugar of less than 60 and greater than 450 and SN to perform blood sugar testing as needed. Documentation showed no patient blood sugar readings on SN visit notes dated 07/14/22. Documentation showed no patient/caregiver refusal of patient blood sugar assessment, no physician notification of declined blood sugar monitoring and no change in orders. Patient #5 A review of a plan of care dated 06/25/22 to 08/23/22 documented a primary diagnosis of Diabetes mellitus Type II. Documentation showed SN to instruct diabetic care and monitor, record and report patient blood sugar of less than 70 and greater than 350 and SN to perform blood sugar testing as needed; and to monitor/record patient reported weight and report to physician weight gain of two pounds in one day or five or more pounds in a week. Documentation showed no patient blood sugar readings on SN visit notes dated 06/10/22, 06/13/22, 06/17/22, 06/29/22 and no patient weight assessment on 06/29/22 and on 07/20/22. Documentation showed no patient/caregiver refusal of patient blood sugar or weight assessment, no physician notification of declined blood sugar monitoring and weight assessment and no change in orders. Patient #7 A review of a plan of care dated 06/14/22 to 08/12/22 documented a primary diagnosis of stage IV pressure ulcer. Documentation showed SN to instruct diabetic care and monitor, record and report patient blood sugar of less than 70 and greater than 250 and SN to perform blood sugar testing as needed. Documentation showed no patient blood sugar readings on SN visit notes dated 06/21/22, 06/30 22, 07/06/22 and on 07/13/22. A physician’s order dated 07/07/22 documented additional SN visit to assess wound to toe for signs and symptoms of infection. Documentation showed no additional SN visits was conducted. Documentation showed no patient/caregiver refusal of patient blood sugar assessment or additional SN visit to assess the wound site, no physician notification of declined blood sugar monitoring or refusal of additional SN visit to assess the wound site and no change in orders. On 07/27/22 at 11:00 a.m., Staff A stated: SN should have conducted assessment of patient weight for Patients #1 and #5;SN should have conducted assessment of patient blood sugars for Patients #1, 2, 5 and #7 and;SN should have conducted assessment of patient wound site for signs and symptoms of infection for Patient #7.