Every finding on record at Ascent Home Health and Hospice Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/12/23 to 12/14/23. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced re-certification survey at the agency on 12/12/23 to 12/14/23. 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 clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A, B, and C. Deficiencies were cited as a result of the re-certification survey. Glossary: Pts Patients POC Plan of Care SN Skilled Nurse/Nursing

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN notified the physician of blood pressure levels outside the ordered parameters for one (Patient #3) of twelve patients; 2. SN provided treatment as ordered for one (Pt #4) of twelve patients; 3. SN notified the physician of pain levels outside the ordered parameters for one (Patient #5) of twelve patients; and 4. SN frequencies were followed as ordered for two (Patient #6 and 12) of twelve patients. 1. Patient #3 A review of the POC dated 09/13/23 to 11/11/23 showed an order for the physician to be notified of diastolic blood pressure less than 60. A review of a vital signs record showed diastolic readings of 58 (9/18/23), 58 (9/25/23), 41 (10/2/23), 56 (10/16/23), 52 (10/23/23), and 51 (11/6/23). Documents showed no physician notification for the diastolic blood pressure readings less than 60. 2. Patient #4 A review of the POC dated 09/23/23 to 11/21/23 showed an order for SN to provide bilateral ear irrigation for ear wax removal monthly or as needed for prevention of ear wax impaction. A review of clinical records showed no ear irrigation treatments were provided. Documentation showed no refusal of services from the patient or caregiver and no physician order for a change in treatment. 3. Patient #5 A review of the POC dated 09/10/23 to 11/08/23 showed an order for the physician to be notified of pain greater than five out of ten. A review of a SN note dated 10/25/23 showed the patient’s reported pain as an eight out of ten. Documents showed no physician notification for the reported pain greater than five. 4. Patient #6 A review of a physician’s order dated 10/04/23 showed a SN frequency of once a week for eight weeks and two as needed, from 10/09/23 to 12/02/23. A review of a SN missed visit note dated 10/23/23 documented the reason the missed visit as other schedule conflicts, and no other visits documented for the week of 10/22/23 to 10/28/23. 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 #12 A review of the POC dated 10/14/23 to 12/12/23 showed a SN frequency of once a week for eight weeks and two as needed. A review of a SN missed visit note dated 10/26/23 documented the reason the missed visit as patient in care of family, and no other visits documented for the week of 10/22/23 to 10/28/23. 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. On 12/14/23 at 2:23 p.m., Staff A stated: 1. there were no documentation of physician notification of the diastolic blood pressures being out of parameters for Patient #3; 2. the ear treatment were not provided as ordered by the physician for Patient #4; 3. there were no documentation of physician notification of the pain level being out of parameters for Patient #5; and 4. the SN frequencies for Patient’s #6 and #12 were not met as ordered by the physician.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a home health aide supervisory visit were completed every 14 days for two (Patients #1 and 2) of seventeen patients. Patient #1 A plan of care dated 09/05/23 to 11/03/23 showed a home health aide visit frequency of once a week for eight weeks. A review of the clinical record showed home health aide visits were completed on 09/12/23, 09/18/23, 09/25/23, 10/02/23, 10/09/23, 10/18/23, 10/25/23, and 11/01/23, with no supervisory aide visits conducted from 10/11/23 to 11/03/23 (24 days without supervisory visits). Patient #2 A plan of care dated 09/12/23 to 11/10/23 showed a home health aide visit frequency of once a week for one week and twice a week for eight weeks. A review of the clinical record showed home health aide visits were completed on 09/15/23, 09/18/23, 09/22/23, 09/25/23, 09/29/23, 10/02/23, 10/06/23 and 10/09/23, 10/13/23, 10/16/23, 10/19/23, 10/23/23, and 10/27/23, with no supervisory aide visits conducted from 10/03/23 to 10/29/23 (27 days without supervisory visits). On 12/14/23 at 2:30 p.m., Staff A stated the supervisory visits were not completed every 14 days for Patient's #1 and #2.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 01/12/21 to 01/13/21. Deficiencies were cited as a result of the Medicare 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), §485.625(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 the review/revision of the community-based risk assessment (All Hazards Risk Assessment) for all employees and 115 current patients Findings: A review of agency administrative records and emergency preparedness records showed a facility-based and community-based risk assessment from the third quarter 2017 that showed no review or revision since it's development. Documentation showed no review or update of the community-based risk assessment for calendar years 2018, 2019 or 2020. On 01/13/20 at 11:10 am, Staff A stated the only All Hazards Risk Assessment at the agency was from the third quarter of 2017.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster exercises and drills were completed every two years affecting current and future patients and all staff members. Findings: A review of administrative and emergency preparedness records showed no disaster table-top exercises or community drills for 2019 and 2020. On 01/13/20 at 11:10 am, Staff A stated the agency had no documentation which showed emergency preparedness disaster table-top exercises or community drills every two years.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency 01/12/21 to 01/13/21 An entrance conference was conducted with Staff A. The survey process was explained and questions were answered. Staff A and 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 Medicare re-certification survey. GLOSSARY: EMR Electronic Medical Record POC Plan of Care Pt Patient PT Physica Therapy SOC Start of Care SN Skilled Nursing VS Vital Signs

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician 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 an individualized Plan of Care for one (Patient #7) of seven patients. Findings: Pt #7 A review of the clinical record showed a SOC dated 12/16/20 with no POC for orders, services, disciplines, the frequency of discipline visits ordered by the physician, instructions or goals. On 01/13/21 at 11:50 am, Staff A stated there was no POC in the EMR for Pt #7.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure POC orders included: 1) VS and/or pain parameters for three (Pt #1, 3 and 4 ) of seven patients; 2) frequency of PT visits for one (Pt #1) of seven patients. Findings: Pt #1 A review a POC dated 11/20/20 to 01/18/21 showed a secondary diagnosis of hypertension. Documentation showed no VS parameters for physician notification of elevated blood pressure. Documentation showed no orders for PT visits although PT visits were completed 12/04/20, 12/09/20, 12/11/20, 12/22/20 and 12/30/20. Pt #3 A review a POC dated 07/10/20 to 09/07/20 showed a secondary diagnosis of hypertension. Documentation showed no VS parameters for physician notification of elevated blood pressure. Pt #4 A review a POC dated 09/25/20 to 11/07/20 showed a secondary diagnoses of hypertension. Documentation showed no VS parameters for physician notification of elevated blood pressure. On 01/13/21 at 1:22 pm, Staff A stated the POC should include: 1) VS parameters for Pt #1, 3 and 4; 2) Physical Therapy orders and frequency for Pt #1.

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 the physician was notified of missed visits for two (Patient #1 and 4) of seven patients. Findings: Pt #1 A review of a POC dated 11/20/20 to 01/18/21 showed a SN frequency of once a week for nine weeks. Documentation showed the SN frequency changed to twice a week for two weeks on 12/03/20. Documentation showed no skilled visit completed 12/18/20 and no physician notification the missed visit. Pt #4 A review of a POC dated 09/25/20 to 11/23/20 showed a SN frequency of once a day for fourteen days. Documentation showed no skilled visit completed 10/03/20 and no physician notification of the missed visit. On 01/13/21 at 1:22 pm, Staff A stated the physician was not notified of missed visits for Pt #1 and 4.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician 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 the ordered frequency was followed for two (Pt #5 and 6) of seven patients. Findings: Pt #5 A review of the POC dated 12/27/20 to 02/24/21 ordered SN visits at a frequency of three times a week for eight weeks and then twice a week for one week. Clinical documentation showed no SN visits completed the weeks of 12/27/20 to 01/02/21 (three missing visits) and 01/03/21 to 01/09/21 (three missing visits). Documentation showed no patient/family refusal of care and no ordered change in SN frequency. Pt #6 A review of the POC dated 12/11/20 to 02/08/21 ordered SN visits at a frequency of once a week for one week, twice a week for eight weeks and then once a week for one week. A review of clinical records showed one visit the week of 12/27/20 to 01/02/21 (one missing visit). Documentation showed no patient/family refusal of care and no ordered change in SN frequency. On 01/13/21 at 1:51 pm, Staff A stated: 1) Visits were not completed as scheduled; 2) Visits should be documented in the EMR within 48 hours of the visit.