Every finding on record at Arbuckle Home Health, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/24/26 - 02/25/26. 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 02/24/26 - 02-25/26. The 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 and clinical issues.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that a skilled nurses note was completed within 24 hours of the skilled nurse visit for one (Pt #5) of nine patients. Findings: Pt #5 A review a nurses note dated 02/18/26 for the certification period of 01/19/26 - 03/19/26 showed the vital sign section was blank (no temperature, no pulse, no respirations, no blood pressure, and no blood sugar). On 02/25/26 at 12:00 pm, Staff A stated: 1) The note was not completed; 2) The nurse has 24 hours to complete a nurses note.

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 governing body failed to ensure an annual budget was approved for all patients and staff. Findings: A review of governing body records showed no annual budget was approved for the Calendar years 2024 and 2025. On 02/25/26 at 11:30 am, Staff A stated the governing body records did not indicate annual approval of the budget for 2024 and 2025.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/22/23 through 02/23/23. 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 in conjunction with a complaint (61250) survey at the agency on 02/22/23 to 02/23/23. 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 and clinical issues. Findings were discussed during an informal exit conference with Staff A. Deficiencies were cited as a result of the re-certification survey. No deficiencies were cited related to the complaint 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 an individualized plan of care included care and services provided for the management of the primary diagnosis for two (Patients #2 and 4) of 7 patients. Patient #2 A review of the plan of care dated 12/22/22 to 02/19/23 showed a primary diagnosis of lymphedema and documented no care and services for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 11/25/22 to 01/23/23 showed a primary diagnosis of monoplegia and documented no care and services for the management of the primary diagnosis. On 02/23/23 at 11:45 am, Staff A stated the plan of care for Patients #2 and 4 did not include care and services for the management of the primary diagnosis.