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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/10/23 to 10/11/23. 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 10/10/23 to 10/11/23. 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 administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C and D. Standard level deficiencies were cited as a result of the survey. Glossary: HHA Home Health Agency PT physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse ST speech therapy

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to: 1. Educate the patient on potential health outcomes related to refusal of PT and ST visits; and 2. Notify the physician of the patient's imminent discharge from agency services for continued refusal of PT and OT visits for one (Patient #15) of 17 patients. Findings: Patient #15 A review of a POC for 12/07/22 to 02/03/23 showed a PT visit frequency of one month one for evaluation and treatment, then two times a week and an ST visit frequency of one month one for evaluation and treatment, then one time a week. Documentation showed missed PT visits on 12/17/22, 12/24/22, 12/29/22 and on 01/06/23 and; missed ST visits on 12/20/22, 01/05/23, 01/10/23, 01/17/23 and on 01/24/23. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of PT and ST visits; and showed no documentation of notification to the physician of the patient's imminent discharge from agency services for continued refusal of PT and ST visits. On 10/11/23 at 2:17 p.m., Staff A stated: 1. The agency made no attempts to educate the patient of potential health outcomes related to refusal of PT and ST visits; and 2. No physician notification of the patient's imminent discharge from agency services for continued refusal of PT and OT visits.

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 patient POC included: 1. Site of wound care interventions for one (Patient #16) of 17 and; 2. Pain reporting parameters for physician notification for one (Patient #16) of 17 patients. Findings: Patient #16 A review of the POC dated 06/07/23 to 08/02/23 showed orders for SN to perform wound site care and assess/monitor patient’s reported pain levels every visit. POC documentation showed wound site care of: cleanse with normal saline, apply Olfoam, 4x4 gauze, ABD pad and secure with kerlex and coban three times a week. Documentation showed no location of the wound site other than ‘to plantar area’ and; SN to assess/monitor/instruct patient reported pain levels and interventions for management of pain but documented no physician reporting parameter for intervention. Documentation showed on 06/12/23 patient reported pain level of 8, 06/28/23 a pain level of 7, 07/07/23 a pain level of 7 and on 07/10/23 a reported pain level of 8. Documentation showed no physician notifications and no changes in orders. At 2:18 p.m., Staff A stated the POC for patient #16 should have included identification of the wound site and reported pain level parameter for physician notification/intervention.

Communication with all physicians CFR(s): 484.60(d)(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 two (Patient #1 and #4) of 17 patients. Findings: Patient #1 A plan of care dated 08/22/23 to 10/20/23 documented a principal diagnosis of fracture right tibia and showed a SN visit frequency of one time a week for nine weeks for SN to change Huber needle to port catheter site (intravenous access device in use for IV antibiotic therapy) and flush per protocols each weekly visit. A SN note dated 10/02/23 documented the Huber needle dislodged from the port catheter, SN was not able to access the port catheter site to replace the Huber needle to reestablish the intravenous access and the patient was sent to the Emergency Medicine Department for care. Documentation showed no physician notification the Huber needle dislodged from the port catheter site, SN was not able to access the port catheter site to replace the Huber needle and the patient was sent to the Emergency Medicine Department for care. On 10/11/23 at 1:52 p.m, Staff A stated the nurse should have notified the physician the Huber needle dislodged from the port catheter, SN was not able to access the port catheter site to replace the Huber needle to reestablish the intravenous access and the patient was sent to the Emergency Medicine Department for care. Patient #4 A plan of care dated 09/06/23 to 11/04/23 documented a primary diagnosis of left lower extremity wound and showed a SN visit frequency of one time every other week for nine weeks for SN to perform wound site care of: cleanse with normal saline, apply Santyl (an autolytic medication for tissue debridement), cover with Adaptic, 4x4 gauze and Kerlex dressing materials. A SN visit notes dated 09/12/23 and on 09/26/23 documented the wound site was healed. Documentation showed no physician notification the wound site had healed and showed no changes in orders. On 10/11/23 at 2:02 p.m, Staff A stated the physician should have been notified the wound site had healed and orders to discontinue the wound site care obtained.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. Findings: A review of QAPI Program activities and records for calendar years 2021, 2022 and 01/01/23 to 10/10/23 showed no governing body oversite of the agency’s QAPI program. On 10/11/23 at 1:40 p.m., Staff A stated documentation showed no governing body oversite of the conduction of the agency’s QAPI Program activities for calendar years 2021, 2022 and 01/01/23 to 10/10/23.

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 services were provided as ordered on the POC’s: 1. SN to assess/monitor/report and instruct patient reported pain levels for four (Patients #1, 2, 3 and 11) of 17 patients; 2. SN to assess/monitor/report and instruct patient blood pressure level for one (Patients # 2) of 17 patients; 3. SN to conduct ordered visit frequency for five (Patients #2, 8, 12, 16 and 17) of 17 patients and; 4. SN to administer Vitamin B12 injection every 2 weeks for one (Patients #5) of 17 patients. Findings: Patient #1 A review of the POC dated 08/22/23 to 10/20/23 showed orders for SN to conduct assessment/monitoring/instruction of pain every visit and notify the physician of patient report of pain >7. Documentation showed during SN visit on 10/09/23 patient reported pain level of 8. Documentation showed no physician notification of patient reported pain level and no change in orders. Patient #2 A review of the POC dated 08/22/23 to 10/20/23 showed orders for SN visit frequency of three times a week or nine weeks for SN to conduct assessment/monitoring/instruction of pain and BP every visit and notify the physician of patient report of pain >7 and BP systolic >180 and diastolic >90. Documentation showed during SN visits on 08/21/23 BP 233/126, 08/23/23 BP 189/119, 08/25/23 BO 203/122, 08/30/23 BP 202/132, 09/06/23 BP 180/110 and pain level of 8, 09/08/23 BP 150/120, 09/13/23 BP 180/120, 09/18/23 BP 170/110, 09/25/23 B 150/120 and on 09/27/23 BP 140/110. Documentation showed that during week of 09/10/23 to 09/16/23 a SN visit was conducted on 09/13/23 (three visits ordered, one visit conducted). Documentation showed no patient refusal of visits, no physician notification of patient BP levels and reported pain level and no change in orders. Patient #3 A review of the POC dated 09/24/23 to 11/22/23 showed orders for SN to conduct assessment/monitoring/instruction of pain every visit and notify the physician of patient report of pain >7. Documentation showed during SN visit on 10/05/23 patient reported pain level of 9. Documentation showed no physician notification of patient reported pain level and no change in orders. Patient #5 A review of the POC dated 09/07/23 to 11/05/23 showed orders for SN visit frequency of one time every other week for nine weeks for SN to administer Vitamin B12 subcutaneous injections every two weeks. Documentation showed during SN visit on 09/07/23 the medication was administered. Documentation showed that during week of 09/17/23 to 09/23/23 no SN visit was conducted to administer the medication (one visit ordered, no visit conducted). Documentation showed no patient refusal of visit, no physician notification of missed visit and no change in orders. Patient #8 A review of the POC dated 09/16/23 to 11/14/23 showed orders for SN visit frequency of two times week for nine weeks. Documentation showed that during week of 09/17/23 to 09/23/23 SN visit was conducted on 10/05/23 (two visits ordered, one visit conducted). Documentation showed no patient refusal of visit, no physician notification of missed visit and no change in orders. Patient #11 A review of the POC dated 09/25/23 to 11/23/23 showed orders for SN to conduct assessment/monitoring/instruction of pain every visit and notify the physician of patient report of pain >6. Documentation showed during SN visit on 10/09/23 patient reported pain level of 7. Documentation showed no physician notification of patient reported pain level and no change in orders. Patient #12 A review of the POC dated 08/31/23 to 10/29/23 showed orders for SN visit frequency of one time every other week for nine weeks. Documentation showed that during week of 09/24/23 to 09/30/23 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient refusal of visit, no physician notification of missed visit and no change in orders. Patient #16 A review of the POC dated 06/07/23 to 08/02/23 showed orders for SN visit frequency of three times week for eight weeks. Documentation showed that during week of 06/11/23 to 06/17/23 no SN visit was conducted (one visits ordered, no visit conducted). Documentation showed no patient refusal of visit, no physician notification of missed visit and no change in orders. Patient #17 A review of the POC dated 01/04/23 to 03/04/23 showed orders for SN visit frequency of one time week for four weeks, then one time every other week for three weeks. Documentation showed that during week of 02/12/23 to 02/17/23 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient refusal of visit, no physician notification of missed visit and no change in orders. On 10/11/23 at from 1:52 to 2:25 p.m., Staff A stated: 1. Patient reported pain levels greater than the ordered reporting parameters for patients #1, 2, 3, 11 and 12 should be reported to the physician; 2. Blood pressure level greater than the ordered reporting parameters for patients #2 should be reported to the physician; 3. SN visit frequencies should be conducted as ordered for patients #2, 8, 16 and 17 and; 4. Vitamin B12 injection for patients #5 should have been completed as ordered.

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 four (Patients #7, 13, 14 and 17) of 17 patients. Findings: Patient #7 A review of the clinical record documented the patient was hospitalized on 09/27/23 and showed a resumption of care to agency services on 10/03/23. Documentation showed no transfer summary of care from the agency on 09/27/23 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. Patient #13 A review of the clinical record documented the patient was transferred to inpatient hospital services on 08/08/23. Documentation showed no transfer summary was provided to the inpatient hospital service provider. Patient #14 A review of the clinical record documented the patient was transferred to inpatient hospital services on 06/22/23. Documentation showed no transfer summary was provided to the inpatient hospital service provider. Patient #17 A review of the clinical record documented the patient was transferred to inpatient hospital services on 02/17/23. Documentation showed a transfer summary was provided to the inpatient hospital service provider on 02/20/23 (three days after the transfer of care). Documentation showed no communications between the agency and the inpatient hospital service provider prior to 02/20/23. On 10/11/23 at 2:06 to 2:20 p.m., Staff A stated completed transfer/discharge summaries for patients #7, 13, 14 and 17 should have been provided to the receiving service providers at the time of the patient’s transfer from agency services.