Every finding on record at Carter Healthcare of Central Oklahoma, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/03/24 to 12/05/24. 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 12/03/24 to 12/05/24. An entrance conference was conducted with Staff A, B and C. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues and Staff B was identified as an additional contact person for administrative issues. Findings were discussed during an informal exit conference with Staff A and D. Standard level deficiencies were cited as a result of the survey. No deficiencies were cited as a result of the complaint survey. Glossary: HHA Home Health Agency HHCOC Home Health Change of Care PT Physical therapy POC Plan of Care SN skilled nurse

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or Home Health Change of Care notice prior to discharge from agency services were provided to two (Patients #13 and 15) of 18 patients. Findings: Patient #13 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 06/06/24. On 12/05/24 at 11:20 a.m., Staff A stated there was no ABN or HHCOC notices in the clinical record for patient #3, prior to being discharged from the agency for changes in payor source. Patient #15 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 07/03/24. On 12/05/24 at 11:30 a.m., Staff A stated there was no ABN or HHCOC notices in the clinical record for patient #15, prior to being discharged from the agency for no insurance authorization for payment.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Show documentation of the problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services for one (Patient #17) of 18 patients; 2. Educate the patient on potential health outcomes from discontinued HHA care and services for one (Patient #17) of 18 patients; 3. Notify the physician of the patient's behaviors that impeded the HHA from providing care and services for one (Patient #17) of 18 patients and; 4. Inform the physician of the patient’s imminent discharge from the HHA for cause for one (Patient #17) of 18 patients. Findings: Patient #17 A review of a plan of care for 08/25/24 to 10/23/24 showed an SN visit frequency of one time a week for nine weeks for SN to assess, instruct and perform nephrostomy tube site care with weekly dressing changes. Documentation showed missed SN visits on 08/30/24, 09/06/24, 09/20/24, 10/04/24 and on 10/11/24 (five of nine ordered SN visits) were auto faxed to the ordering medical provider of record. Documentation showed no follow up communications or coordination of care attempts to the ordering medical provider related to continued missed SN visits. Documentation showed no identified problems encountered by the HHA related to behaviors or conditions that impeded the HHA from providing care and services, no communication or education attempts to the patient for potential health outcomes resulting from discontinued HHA care and services, no physician notification of the patient's behaviors and living conditions that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 10/23/24. On 12/05/24 at 11:40 a.m., Staff A stated there was no documentation of: 1. Problems encountered by the HHA related to behaviors and conditions that impeded the HHA from providing care and services; 2. Patient education of potential health outcomes from discontinued HHA care and services; 3. Physician notification of the patient's behaviors and living conditions that impeded the HHA from providing care and services and; 4. Physician notification of the patient’s imminent discharge from the HHA for cause.

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 individualized patient POC included an individualized patient pain reporting parameters for two (Patients #1 and #4) of 18 patients. Findings: Patient #1 A review of the POC dated 10/06/24 to 12/04/24 showed orders for PT to conduct assessment of patient pain level every visit. Documentation showed no medical provider pain reporting parameters on the POC. Documentation showed PT visits were conducted on 10/09/24 with a reported pain level of 2, 10/24/24 with a reported pain level of 4, 11/08/24 with a reported pain level of 2 and on 11/26/24 with a reported pain level of 4. Documentation showed no physician notifications and no change in orders. On 12/05/24 at 10:40 a.m., Staff A stated the POC for patient #1 should have included physician pain reporting parameters. Patient #4 A review of the POC dated 10/16/24 to 12/14/24 showed orders for SN and PT to conduct assessment of patient pain level every visit. Documentation showed no medical provider pain reporting parameters on the POC. Documentation showed PT visits were conducted on 10/29/24 with a reported pain level of 4, 10/31/24 with a reported pain level of 2, 11/05/24 with a reported pain level of 1, 11/07/24 with a reported pain level of 1, 11/12/24 with a reported pain level of 1, SN visit on 11/13/24 with a reported pain level of 3, 11/18/24 with a reported pain level of 1 and on 11/26/24 with a reported pain level of 1. Documentation showed no physician notifications and no change in orders. On 12/05/24 at 10:55 a.m., Staff A stated the POC for patient #4 should have included physician pain reporting parameters.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for one (Patient #7) of 18 patients. Findings: Patient #7 A review of a plan of care dated 10/05/24 to 12/03/24 documented a primary diagnosis of Alzheimer’s and showed orders for SN visit frequency of two times a month times two months. Documentation showed medical provider orders dated 10/23/24 for SN to assess wound site right antecubital fossa and perform wound site care every other day after the patient experienced a fall. Documentation showed SN missed visit notification dated 10/28/24 was auto faxed to the physician due to patient refused wound care. Documentation showed no follow up SN visit to assess the wound site until the SN recertification assessment visit on 12/03/24 (36 days later). Documentation showed no attempt to make up the SN visit during the week it was ordered from the date the visit was missed on 10/28/24. On 12/05/24 at 10:58 a.m., Staff A stated documentation showed no attempt to make up the SN visit during the week of 10/28/24 and showed no follow up COC with the medical provider related to wound assessment and care of the right antecubital fossa wound site.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner 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: SN conducted visit frequency as ordered on the POC for one (Patient #9) of 18 patients; PT conducted visit frequency as ordered on the POC for one (Patient #9) of 18 patients. Findings: Patient #9 A review of the POC dated 11/15/24 to 01/13/25 showed orders for SN visit frequency one time a week for nine weeks and PT visit frequency two times a week for five weeks, one time a week for one week, zero time a week for one week, two times a week for one week, then one times a week for one week. Documentation showed no SN visits were conducted between 11/17/24 and 12/03/24 (three visits ordered, no visits conducted) and no PT visits were conducted between 11/17/24 and 12/03/24 (six visits ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 12/05/24 at 11:05 a.m., Staff A stated: 1. SN and PT visits were not conducted due to no insurance payment authorization; 2. Documentation showed no notice of non-coverage was provided to the patient and; 3. Documentation showed no physician notification or change in orders.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical records were complete for one (Patient #7) of 18 patients. Findings: Patient #7 A review of the clinical record showed incomplete documentation (blank visit note designated as ‘not started’ as of a review date of 12/05/24) of a PT visit conducted on 11/27/24. On 12/05/24 at 10:54 a.m., Staff A stated PT visit notes should have been completed within 1 business day of when the visit was conducted.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided for two (Patients #14 and #18) of 18 patients. Findings: Patient #14 A review of the clinical record documented discharge to hospice services from the agency on 06/30/23. Documentation showed no discharge summary was provided to the hospice service provider. Patient #18 A review of the clinical record documented transfer to inpatient service provider with subsequent discharge from the agency on 09/13/24. Documentation showed no transfer/discharge summary was provided to the inpatient service provider. On 12/05/23 at 11:25 a.m. to 11:42 a.m., Staff A stated no transfer/discharge summary was sent to the receiving service providers for patients #14 and #18.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/03/22 to 01/05/22.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 01/03/22 to 01/05/22. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff C and D were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff C and D. Deficiencies were cited as a result of the re-certification survey. GLOSSARY: QAPI Quality Assessment and Performance Improvement

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 two (Patients #3 and 12) of seventeen patients. Patient #3 A review of the plan of care dated 11/07/21 to 01/05/22 showed a primary diagnosis of hypertensive heart with heart failure and documented a skilled nurse frequency of one visit per week for nine weeks. The plan of care documented no interventions to notify the physician of significant weight gain or weight loss in relation to the primary disease process. A review of the electronic medical record showed the following: A skilled nurse assessment dated 11/11/21 documented no patient weight. A skilled nurse assessment dated 11/18/21 documented a patient weight of 52 pounds. A skilled nurse assessment dated 12/03/21 documented a patient weight 154 pound (102-pound weight gain), with no physician notification of the weight gain. Patient #12 A review of the plan of care dated 09/23/21 to 11/21/21 showed a primary diagnosis of congestive heart failure and documented a skilled nurse frequency of one visit per week for nine weeks. The plan of care documented no interventions to notify the physician of any significant weight gain or weight loss in relation to the primary disease process. A review of the electronic medical record showed the following: A skilled nurse assessment dated 11/01/21 documented no patient weight. A skilled nurse assessment dated 11/15/21 documented a patient weight of 310 pounds. A skilled nurse assessment dated 11/22/21 documented a patient weight of 317 pounds (a seven-pound weight gain in one week), with no physician notification of a significant weight gain. A skilled nurse assessment dated 11/30/21 documented a patient weight 311 pounds (a six-pound weight loss in one week), with no physician notification of a significant weight loss. On 01/05/22 at 9:13 am., Staff C stated the plan of care for Patients #3 and 12 should have documented interventions to notify the physician of significant weight gain or weight loss in relation to the primary disease process.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency for calendar years 2019, 2020 and 2021. On 01/05/22 at 11:10 am, Staff C stated they had no QAPI documentation which measured and tracked agency performance strategies to ensure improvements were sustained for calendar years 2019, 2020 and 2021.