Every finding on record at At Home in Oklahoma, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/02/24 to 04/04/24. 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 an emergency preparedness disaster tabletop exercises or disaster drill were conducted for calendar years 2022 and 2023 for all patients and current staff members. A review of the agency's disaster/emergency preparedness records showed no tabletop exercise or disaster drill for the surveyed agency within the past two years. On 04/04/24 at 10:05 a.m., Staff B stated there was no documentation of emergency preparedness disaster table-top exercises or drills for 2022 and the agency did not conduct any exercises or drills for 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/02/24 to 04/04/24. 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 and B. Deficiencies were cited as a result of the re-certification survey. Glossary: POC Plan of Care SN Skilled Nurse/Nursing 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 the initial assessment was performed within 48 hours of the referral for four (Patients #1, 4, 6 and 7) of nine patients. Pt #1 A review of the clinical record showed a patient referral dated 06/01/23. A review of clinical documentation showed an initial patient assessment and SOC dated 06/06/23 (five days later). 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 to delay the initial assessment. Pt #4 A review of the clinical record showed a patient referral dated 11/03/23. A review of clinical documentation showed an initial patient assessment and SOC dated 11/15/23 (12 days later). 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 to delay the initial assessment. Pt #6 A review of the clinical record showed a patient referral dated 06/28/23. A review of clinical documentation showed an initial patient assessment and SOC dated 07/04/20 (six days later). 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 to delay the initial assessment. Pt #7 A review of the clinical record showed a patient referral dated 10/02/23. A review of clinical documentation showed an initial patient assessment and SOC dated 10/13/23 (11 days later). 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 to delay the initial assessment. On 04/04/24 at 9:46 am, Staff A stated the initial assessment for Patients #1, 4, 6 and 7 were not completed within 48 hours of the referral.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT 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 six (Patients #1, 2, 3, 4, 5, and 6) of nine patients; 2. SN notified the physician of blood sugar results outside the ordered parameters for one (Patient #1) of nine patients; and 3. SN obtained an order for oxygen administration for one (Patient #6) of nine patients. 1. Patient #1 A review of the POC dated 02/01/24 to 03/31/24 showed a SN frequency of zero visits per week for one week and one visit per week for eight weeks. A review of the medical record showed a SN missed visit dated 03/01/24 which documented the reason as no answer to locked door, and no other visits for the week of 02/25/24 to 03/02/24. 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. Patient #2 A review of the POC dated 01/06/24 to 03/05/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 01/15/24 which documented the reason as unable to get there due to weather, and no other visits for the week of 01/14/24 to 01/20/24. 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. Patient #3 A review of the POC dated 12/10/23 to 02/07/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 01/17/24 which documented the reason as refused due to weather, and no other visits for the week of 01/14/24 to 01/20/24. 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. Patient #4 A review of the POC dated 01/14/24 to 03/13/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 03/07/24 which documented the reason as no answer to phone call, and no other visits for the week of 03/03/24 to 03/09/24. 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. Patient #5 A review of the POC dated 12/12/23 to 02/09/24 showed a SN frequency of two visits per week for nine weeks. A review of the medical record showed a SN missed visit dated 01/17/24 which documented the reason as doctor-clinic appointment, and one other SN visit for the week of 12/17/23 to 12/23/23 (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 #6 A review of the POC dated 11/01/23 to 12/30/23 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed no SN visits were made for the week of 11/05/23 to 11/11/23. 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. 2. Patient #1 A review of the POC dated 02/01/24 to 03/24/24 showed an order for the physician to be notified of blood sugar levels greater than 160. A review of clinical records showed the following: A SN visit dated 02/20/24 showed a blood sugar result of 199. A SN visit dated 03/13/24 showed a blood sugar result of 342. Documents showed no physician notifications for blood sugar results greater than 160. 3. Patient # 6 A review of the POC dated 11/01/23 to 12/30/23 showed no order for oxygen to be administered to the patient. A review of the medical records showed the following: A SN visit note dated 11/15/23 documented the patient continuously received 2 liters of oxygen per minute via tracheostomy mask. Documents showed no oxygen administration was ordered by the physician. A SN visit note dated 11/23/23 documented the patient continuously received 5 liters of oxygen per minute via tracheostomy mask. Documents showed no oxygen administration was ordered by the physician. A SN visit note dated 12/07/23 documented the patient continuously received 4 liters of oxygen per minute via tracheostomy mask. Documents showed no oxygen administration was ordered by the physician. On 04/04/24 at 9:46 a.m., Staff A stated: 1. the SN frequencies for Patients #1, 2, 3, 4, 5 and 6 were not met as ordered by the physician; 2. there was no documentation of physician notification of the blood sugar results being out of parameters for Patient #1; and 3. the plan of care did not show an order for oxygen use and there were no orders by the physician to administer oxygen for Patient #6.

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 performance improvement projects were conducted for all current patients and staff. A review of the agency’s documentation showed no records of performance improvement projects implemented, in development, on-going or completed for calendar year 2022 and 2023. On 04/04/24 at 10:12 a.m., Staff B stated there were no performance improvement projects documented for 2022 and 2023.

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 agency failed to ensure governing body oversite of: 1. Ongoing patient centered QAPI Program activities for calendar year 2023; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023; and 3. Agency program evaluations for calendar year 2023 for all patients and employees. A review of administrative records showed no governing body over-site of ongoing patient centered QAPI Program activities; operating budget, capital expenditure plan and allocation of resources activities and agency program evaluations for calendar year 2023. On 04/04/24 at 10:08 a.m., Staff B stated administrative records showed no governing body over-site of ongoing patient centered QAPI Program activities, operating budget, capital expenditure plan and allocation of resources activities and agency program evaluations for calendar year 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 04/06/21 to 04/07/21. A deficiency was cited as a result of the 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 hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 69 patients and all employees. Findings: A review of administrative records showed no community-based risk assessment which addressed the agency, its patient population, or its employees for the calendar years of 2019 and 2020. On 04/07/21 at 10:25 am, Staff A stated she did not have a copy of the All Hazards Risk Assessment available.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/06/21 - 04/07/21. 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 and clinical issues. Findings were discussed during an informal exit conference with Staff A Deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: POC Plan of Care Pt Patient PT Physical Therapy ROC Resumption of Care SN Skilled Nurse SOC Start of Care

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure complaints were investigated for one of one complainants. Findings: A review of administrative records showed a grievance/complaint form dated 10/07/20. Documentation showed no investigation of the caregivers complaint. Details of the grievance intentionally ommitted from this citation. The complainant requested that another nurse see her father. Documentation noted that the staff in question were spoken with and they had passed their background checks. No investigation into allegations was documented. On 04/07/21 at 11:30 am, Staff A stated documentation provided doesn't show an investigation was completed.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the SN provided wound care as ordered for one (Patient #7) of seven patients. Findings: Patient #7 A review of a POC dated 03/17/21 to 05/15/21 showed no orders for the SN to perform wound care. A review of SN notes showed wound care as follows: 1) 03/19/21 cleaned peg tube site with normal saline, applied split gauze, left heel cleaned with normal saline applied allevyn foam pad, and coccyx cleaned with normal saline, applied skin prep and allevyn pad dressing; 2) 03/22/21 wound care to left heel (cleaned with normal saline, applied foam pad) and coccyx cleaned with normal saline, applied skin prep and foam pad; 3) 03/30/21 coccyx - cleaned with normal saline and applied allevyn foam pad on it. Documentation showed no physician notification of a need for wound care or orders obtained for wound care after the SOC comprehensive assessment 3/17/21. On 04/07/21 at 11:14 am, Staff A stated Pt #7 had no orders for wound care to peg tube site, coccyx or left heel.