Every finding on record at Care Plus Home Health Care, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/18/24 to 11/19/24. 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 11/18/24 and 11/19/24. An entrance conference was conducted with Staff A. Staff B was identified as the contact person for administrative issue and Staff A was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C and D. Deficiencies were cited as a result of the re-certification survey.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a complaint regarding lack of respect for the patient was fully investigated for one (Complainant #1) of one complainant. Complainant #1 A review of administrative records showed a complaint dated 09/19/24 which documented the complainant requested Staff E not return "because she was too rough". The investigation/findings section failed to address any investigation into the patient being treated "rough". The actions taken section of the complaint form failed to address any reference to the "rough" behavior of Staff E. On 11/19/24 at 1:40 pm., Staff A stated the complaint investigation for Complainant #1 failed to document any investigation into the reported "rough" treatment by Staff E.

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 for seven (Patient #1, 2, 3, 4, 5, 6 and 7) of 7 patients. Patient #1 A review of the plan of care dated 08/11/24 to 10/09/24 showed a primary diagnosis of paroxysmal atrial fibrillation with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 08/18/24 to 10/16/24 showed a primary diagnosis of hypertensive heart disease with heart failure with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 09/16/24 to 11/14/24 showed a primary diagnosis of corns and callosities with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 09/20/24 to 11/18/24 showed a primary diagnosis of metabolic encephalopathy with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 07/25/24 to 09/22/24 showed a primary diagnosis of Friedreich ataxia with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 07/18/24 to 09/15/24 showed a primary diagnosis of chronic respiratory failure, unspecified with hypoxia or hypercapnia with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 08/07/24 to 10/05/24 showed a primary diagnosis of type II diabetes mellitus with foot ulcer with no patient specific individualized interventions developed for the management of the primary diagnosis. On 11/19/24 at 1:50 pm, Staff A stated the plan of care for Patients #1, 2, 3, 4, 5, 6 and 7 did not include patient specific individualized interventions for the management of the primary diagnosis.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nurse frequencies were followed as ordered for one (Patient #7) of 7 patients. Patient #7 A plan of care dated 08/07/24 to 10/05/24 showed a primary diagnosis of type II diabetes mellitus with foot ulcer and documented a skilled nurse frequency of one visit per week for one week and two visits per week for eight weeks. A review of the clinical records showed the following: A physician's order dated 08/23/24 showed an order for home health skilled nurse three times weekly except on days completed by wound center. Skilled nurse assessments dated 09/02/24 and 09/06/24 were completed for the week of 09/02/24 to 09/08/24 (two of three completed visits) with no physician orders for a change in frequency, no refusal of visits or offer to reschedule missed visits. A physician's order dated 09/10/24 showed an order for home health skilled nurse three times weekly except on days completed by wound center. Skilled nurse assessments dated 09/09/24 and 09/13/24 were completed for the week of 09/09/24 to 09/15/24 (two of three completed visits) with no physician orders for a change in frequency, no refusal of visits or offer to reschedule missed visits. Skilled nurse assessments dated 09/16/24 and 09/19/24 were completed for the week of 09/16/24 to 09/22/24 (two of three completed visits) with no physician orders for a change in frequency, no refusal of visits or offer to reschedule missed visits. On 11/19/24 at 1:00 pm., Staff A stated the physician ordered frequency was not followed for Patient #7.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/06/21 to 12/07/21. 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 Medicare Complaint (OK00056815) at the agency on 12/06/21 to 12/07/21. 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 issues and Staff B was identified as the contact person for clinical 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: PIP Performance Improvement Project PIPs Performance Improvement Projects QAPI Quality Assessment and Performance Improvement

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure complaint resolution was provided for three (Complaints #1, 2 and 3) of three complaints. Complaint #1 A review of agency records showed complaint received on 06/01/21 which documented a patient requesting staff not to return to her home due to selling inappropriate items. There was no documentation of the complaint being resolved or unresolved. Complaint #2 A review of agency records showed a complaint received on 07/22/21 which documented a patient requesting a new nurse due to supplies not being provided. There was no documentation of the complaint being resolved or unresolved. Complaint #3 A review of agency records showed a complaint received on 08/17/21 which documented a patient's wife reporting a patient being dropped by staff during a shower. There was no documentation of the complaint being resolved or unresolved. On 12/07/21 at 12:30 pm, Staff B stated there was no documented resolution for complaints #1, 2 and 3.

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 the use of oxygen was included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for one (Patient #2) of seven patients. Patient #2 A review of the plan of care dated 08/25/21 to 10/23/21 documented a principal diagnosis of acute chronic obstructive pulmonary disease. Skilled nurse assessments dated 08/25/21, 09/04/21, 09/09/21, 09/16/21, 09/22/21, 09/30/21,10/07/21, 10/15/21 and 10/21/21 documented the use of oxygen. A review of the electronic medication record showed no oxygen included on the medication record. On 12/07/21 at 12:15 pm, Staff B stated oxygen should have been included on the medication list for Patient #2.

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 development of an individualized plan of care for one (Patient #2, 3, 4 and 5) of seven patients. Patient #2 A review of the plan of care dated 08/25/21 to 10/23/21 showed a primary diagnosis of chronic obstructive pulmonary disease, a skilled nurse frequency of one visit per week for nine weeks and documented the physician to be notified of a pain rating greater than 7 on the classic 1-10 pain rating scale. A skilled nurse assessment dated 08/25/21 documented the patient's stated pain goal was 0-3 on the classic pain rating scale. A skilled nurse assessment dated 10/21/21 documented the patient's stated pain goal was 0-3 on the classic pain rating scale. Plan of care documentation showed no identified goal related to pain. Patient #3 A review of the plan of care dated 09/19/21 to 11/17/21 showed a primary diagnosis of systolic and diastolic heart failure, a skilled nurse frequency of one visit per week for nine weeks and documented the physician to be notified of a pain rating greater than 7 on the classic 1-10 pain rating scale. A skilled nurse assessment dated 09/25/21 documented the patient's stated pain goal was 0-3 on the classic pain rating scale. A skilled nurse assessment dated 11/17/21 documented the patient's stated pain goal was 0-3 on the classic pain rating scale. Plan of care documentation showed no identified goal related to pain. Patient #4 A review of the plan of care dated 09/01/21 to 10/30/21 showed a primary diagnosis of diabetes mellitus type II and a skilled nurse frequency of one visit per week for nine weeks and documented the physician to be notified of a pain rating greater than 7 on the classic 1-10 pain rating scale. A skilled nurse assessment dated 09/01/21 documented the patient's stated pain goal was 0-3 on the classic pain rating scale. Plan of care documentation showed no identified goal related to pain. Patient #5 A review of the plan of care dated 08/25/21 to 10/23/21 showed a primary diagnosis of seizures with no skilled nurse services declined by the patient. The plan of care documented skilled nurse was to provide assessment and instruction regarding seizures, instruct on methods to relieve pain, decrease risk of pressure ulcers, instruct on taking weight and fall precautions. The plan of care failed to outline services provided specific to the treatment of the primary diagnosis. On 12/07/21 at 11:20 am, Staff B stated the plan of care for Patients #2, 3 and 4 failed to document the patient identified goal related to pain. Staff B stated the plan of care for Patient #5 failed to properly document services provided and failed to document specific services to treat the primary diagnosis.

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 wound care orders were followed as ordered for one (Patient #1) of seven patients. Patient #1 A review of the plan of care dated 10/13/21 to 12/11/21 showed a primary diagnosis of pressure ulcer to left buttock stage IV with orders to perform wound care utilizing "Aqucel" to wound bed. A physician's order dated 11/17/21 documented wound care orders to utilize "Opticell Ag" to wound bed. Skilled nurse assessments dated 11/24/21,12/02/21 and 12/03/21 documented the use of "Aqucel" to wound bed. On 12/07/21 at 10:40 am, Staff B stated wound care was not followed as ordered for Patient #1.

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 the physician was notified of the deterioration of a pressure ulcer for one (Patient #1) of seven patients. Patient #1 A review of the plan of care dated 10/13/21 to 12/11/21 showed a primary diagnosis of pressure ulcer of left buttock stage IV. A review of the electronic medical record showed the following: A skilled nurse assessment dated 10/13/21 documented the measurement for wound #1 as 3 centimeters long by 3 centimeters wide by 1 centimeter deep. A skilled nurse assessment dated 10/27/21 documented the measurement for wound #1 as 5 centimeters long by 6 centimeters wide by 1 centimeter deep with no documentation of physician notification of increased wound size. A skilled nurse assessment dated 11/03/21 documented the measurement for wound #1 as 5 centimeters long by 7 centimeters wide by 1 centimeter deep with no documentation of physician notification of increased wound size. A skilled nurse assessment dated 11/05/21 documented the measurement for wound #1 as 5 centimeters long by 8 centimeters wide by 1 centimeter deep with no documentation of physician notification of increased wound size. A skilled nurse assessment dated 11/08/21 documented the measurement for wound #1 as 5 centimeters long by 10 centimeters wide by 1 centimeter deep with no documentation of physician notification of increased wound size. On 12/07/21 at 11:25 am., Staff B stated the physician should have been notified the physician of the deterioration in the wound for Patient #1.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of quality indicator data to improve program effectiveness, quality of patient care and overall program improvement for all future patients. A review of administrative records showed no OASIS data collection of quality indicators utilized in the agency's QAPI Program for calendar years of 2019, 2020 and from January 01, 2021 to December 07, 2021.On 12/07/21 at 12:00 pm, Staff B stated they had no analysis of quality indicator data available that showed improved quality of patient care for 2019, 2020 and from January 01, 2021 to December 07, 2021.

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 the review and evaluation of performance improvement projects through their QAPI Program for 93 patients and all employees. A review of QAPI records showed no review or evaluation of performance improvement projects for the calendar years of 2019, 2020 and January 01, 2021 to December 07, 2021. On 12/07/21 at 12:05 p.m., Staff A stated the agency had no documented review or evaluation of performance improvement projects for 2019, 2020 and from January 01, 2021 to December 07, 2021.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1) The Infection Control Program included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency and 2) The Infection Control Program was included in QAPI activities for all agency employees and staff. A review of administrative records showed no ongoing infection control program for the agency or infection control surveillance data for calendar year of 2020 and 01/01/21 to 12/07/21. Additional infection control surveillance documentation was requested and yielded no further reports. On 12/07/21 at 12:00 p.m., Staff B stated: 1. the agency had no comprehensive infection surveillance program in place and 2. no infection surveillance activities were reported through the agency's QAPI program.