Every finding on record at Bios Home Health Care LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/02/24 to 01/04/24. 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 in conjunction with complaint (97515) at the agency on 01/02/24 to 01/04/24. 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. Deficiencies were cited as a result of the re-certification survey. No deficiencies were cited related to the complaint. Glossary: Pts Patients POC Plan of Care SN Skilled Nurse PIP Performance Improvement Program

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 or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner 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 notify the physician of missed SN visits for two (Patients #6 and 9) of ten patients. Patient #6 A review of the POC dated 10/25/23 to 12/23/23 showed a primary diagnosis of pressure ulcer of right buttock, stage 4. The POC also shows a SN frequency of two visits per week for one week and then three visits per week for eight weeks. A review of SN missed visit notes showed the following: A SN missed visit note the week of 10/23/23 to 10/29/23 (one of two visits) showed no notification was made to the physician of the missed visits. A SN missed visit note the week of 10/30/23 to 11/05/23 (two of two visits) showed no notifications were made to the physician of the missed visits. A SN missed visit note the week of 12/11/23 to 12/17/23 (one of three visits) showed no notifications were made to the physician of the missed visits. Patient # 9 A review of the POC dated 09/19/23 to 11/17/23 showed a primary diagnosis of paroxysmal atrial fibrillation. The POC also showed a SN frequency of one visit per week for nine weeks. A review of a SN missed visit note dated 09/21/23 showed no notification was made to the physician of the missed visit. On 01/04/24 at 12:25 pm, Staff A stated no notifications of the missed SN visits were made to the physician for Patient’s #6 and #9.

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 assessed the blood sugar as ordered for one (Patient #1) of ten patients; 2. a medication order was completed as ordered for one (Patient #3) of ten patients; and 3. SN notified the physician of systolic blood pressure levels outside the ordered parameters for one (Patient #6) of ten patients. 1. Patient #1 A review of the POC dated 10/21/23 to 12/19/23 showed an order for SN to assess blood sugar via finger stick during each visit for Patient #1. Clinical records showed no finger sticks were completed and no blood sugar results were documented during SN visits dated 10/23/23, 10/30/23, 11/6/23, 11/14/23, 11/20/23, 11/27/23, 12/08/23, 12/12/23, and 12/18/23. Documents showed no refusal of services from the patient or caregiver and no changes in the physician’s order. 2. Patient #3 A review of a POC dated 10/21/23 to 12/19/23 showed a medication order for Rivaroxaban (common name: Xarelto) 15 mg to be taken by mouth daily. A physician’s order dated 11/16/23 showed an order to discontinue Xarelto and begin taking Apixaban 5 mg BID (twice a day), once Apixaban is received. A review of clinical records showed no Apixaban medication being administered, and no changes were made on Patient #3’s current medications list as ordered by the physician. Documents showed no refusal of medication from the patient or caregiver and no changes in the physician’s order. 3. Patient #6 A review of the POC dated 10/25/23 to 12/23/23 showed an order for SN to notify the physician of systolic blood pressure greater than 170. A review of SN visit dated 11/15/23 showed a systolic blood pressure reading of 178. Documents showed no physician notification for the systolic blood pressure reading greater than 170. On 01/04/23 at 1:15 pm, Staff A stated: 1. SN visits did not show documentation of blood sugar assessments as ordered by the physician for Patient #1; 2. the medication order was not completed as ordered by the physician for Patient #3; and 3. there was no documentation of physician notification of the systolic blood pressure being out of parameters 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 for all current patients and staff. A review of the agency’s documentation showed no records of performance improvement projects implemented, n in development, on-going or completed for calendar year 2022 and 2023. On 01/04/24 at 1:35 p.m., Staff A stated there were no performance improvement projects written out or documented for 2022 and 2023.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 01/26/21 - 01/27/21. No deficiencies were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency 01/26/21 - 01/27/21. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: PIP Perfomance Improvment Plan PIPs Performance Improvment Plans POC Plan of Care Pt Patient Pts Patients QAPI Quality Improvment Performance Improvement SN Skilled Nurse

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 embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for two (Pts #1 and 2) of ten patients. Findings: Pt #1 A review of the plan of care dated 08/02/20 to 09/30/20 showed a principal diagnosis of encounter for change or removal of a surgical wound dressing. The POC showed orders for the SN to perform wound site cleansing with Chlorhexidine and placing Xeroform, (a medication embedded wound care supply material). A review of the electronic clinical record showed the Chlorhexidine and Xeroform were not added to the medication profile. Pt #2 A review of the plan of care dated 12/10/20 to 02/07/21 showed a principal diagnosis of encounter for change or removal of a surgical wound dressing. The POC showed orders for the SN to perform wound site cleansing wound with normal saline and pack with betadine moistened gauze (a medication embedded wound care supply material). A review of the clinical record showed the betadine was not added to the medication profile. On 01/27/21 at 11:30 am, Staff B stated all wound care supplies should be added to the medication profile and the wound care supplies ordered for wound care on Pts #1 and #2 were not on the medication profiles. Staff B stated the Home Health Agency did not review the medication embedded wound care supply materials for patient interactions, effects, or allergies.

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 POC orders included orders for an indwelling urinary catheter for one (Pt #10) of ten patients. Findings: Pt #10 A review a POC dated 10/22/20 to 12/20/20 showed a secondary diagnosis of Encounter for fitting and adjustment of urinary device. Documentation showed no information on frequency of catheter change, if SN or the physician would change the catheter or the size of the catheter and bulb size. On 01/27/21 at 11:50 am, Staff B stated the POC for Pt #10 should include: 1) how often the catheter should be changed; 2) if the nurse or physician should change the catheter; 3) what size catheter and bulb size was used for the patient.

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) wound care was completed as ordered for one (Pt #1) of ten patients; 2) SN frequencies were followed as ordered for one (Pt #9) of ten patients. Findings: Pt #1 A review of the POC dated 08/02/20 to 09/30/20 showed orders for the SN to complete wound care as follows: left breast cleanse periwound with Chlorhexidine, cover skin graft with Xeroform, 4 x 4 gauze and secure with tape daily. SN notes dated 08/03/20, 08/05/20, 08/07/20, 08/10/20, and 08/12/20 (last visit prior to discharge) documented the "periwound cleansed with normal saline , pat dried with sterile gauze, Prisma and 4 x 4 gauze applied covered with bordered gauze." Clinical documentation showed no change in wound care orders. Pt #9 A review of the POC dated 11/09/20 to 01/07/21 showed SN visits scheduled at a frequency of twice a week for one week and then once a week for eight weeks. Documentation showed no SN visits completed from 11/09/20 through 12/16/20 (a total of six visits not competed). Clinical documentation showed no patient refusal of visits, no missed visit notes and no change in physicians orders. On 01/27/21 at 11:11 am, Staff B stated: 1) the wound care orders on the POC for Pt #1 was not followed; 2) the ordered SN frequency was not followed for Pt #9.

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 an order was obtained by a physician for 1) oxygen use for one (Pt #3) of ten patients; 2) increased SN frequency for one (Pt #5) of ten patients. Findings: Pt #3 A review of the clinical record showed a physician communication dated 11/17/20 which documented the patient had an oxygen saturation of 85% and respirations of 27. Documentation showed the SN spoke with physician's office. The office staff reported they would work on obtaining an order for oxygen. A SN visit dated 11/23/20 documented oxygen use at 2.5 liters a minute via nasal cannula. No order for the use of oxygen was found in the medical record. Pt #5 A review of the POC dated 11/28/20 - 01/26/21 showed a SN frequency of once in sixty days. A review of clinical notes showed SN visits completed 12/03/20, 12/07/20, 12/17/20, 12/28/20, 01/06/21, 01/13/21 and 01/22/21. Documentation showed no orders for additional visits, no changes in the ordered frequency and no patient requests for additional visits. On 01/27/21 at 1151 am, Staff B stated there was no order for the use of oxygen for Pt #3 and no orders to increase the SN frequency for Pt #5.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of a wound change prior to discharge for one (Pt #2) of ten patients. Pt #2 A review of a POC dated 12/10/20 - 02/07/21 showed orders for a wound vac to the left heel. A SN assessment dated 12/18/20 documented wound measurements to the left heel of 4.5 cm length x 5.6 cm width x 1.4 cm depth. SN assessment dated 01/08/21 documented wound measurements to the left heel of 5 cm length x 6.8 cm width x 0.5 cm depth. The clinical record showed no physician notification of the increase in wound size On 01/27/21 at 11:30 am, Staff B stated the physician should have been notified of the change in the size of the left heel wound for Pt #2.

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 clinical note completion for one (Pt# 7) of ten patients. Findings: Pt # 7 A review of the POC dated 12/22/20 - 02/19/21 showed orders for skilled nurse visits once a week for nine weeks. Clinical records showed a blank SN visit dated 01/06/21 for the week of 01/03/21 to 01/09/21. On 01/27/20 at 11:55 am, Staff B stated clinical notes should be completed the day of the visit.