Every finding on record at Centerwell Certified Healthcare Corp

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/09/21. 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 at the agency on 06/09/21. 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. Findings were discussed during an informal exit conference with Staff A, B, and C and by telephone with staff D. Standard level deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: POC Plan of Care SN Skilled Nurse

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 to ensure development of an individualized plan of care for one (Patient #7) of seven patients. Findings: Patient #7 A review of the plan of care dated 02/21/21 to 04/21/21 showed a primary diagnosis of pressure ulcer of sacral region, stage IV. Skilled nurse assessments dated 02/21/21, 02/23/21, 02/24/21, 02/26/21, 03/01/21, 03/03/21, 03/05/21, 03/08/21, 03/10/21, 03/12/21, 03/15/21, 03/17/21, 03/19/21, 03/22/21, 03/24/21, 03/26/21, 03/29/21, 03/31/21, 04/05/21, 04/07/21, 04/09/21, 04/12/21, 04/14/21, 04/16/21, 04/19/21 and 04/21/21 each documented the presence of a stage III pressure ulcer to the patient coccyx. On 06/09/21 at 2:18 pm, Staff A stated the plan of care for Patient #7 did not reflect the presence of the stage III pressure ulcer to the patient's coccyx.

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 included wound care treatment details for one (Patient #7) of seven patients. Findings: Patient #7 A review of the plan of care dated 02/21/21 to 04/21/21 showed a primary diagnosis of pressure ulcer of sacral region, stage IV with no wound care orders specific to the treatment of sacral region wound. Skilled nurse assessments dated 02/21/21, 02/23/21, 02/24/21, 02/26/21, 03/01/21, 03/03/21, 03/05/21, 03/08/21, 03/10/21, 03/12/21, 03/15/21, 03/17/21, 03/19/21, 03/22/21, 03/24/21, 03/26/21, 03/29/21, 03/31/21, 04/05/21, 04/07/21, 04/09/21, 04/12/21, 04/14/21, 04/16/21, 04/19/21 and 04/21/21 failed to document wound care provided to the stage IV pressure ulcer to the sacral region and the plan of care failed to give instructions for wound care. On 06/09/21 at 2:18 pm, Staff A stated the plan of care for Patient #7 did not document wound care orders for the stage IV pressure ulcer to the sacral region.

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 skilled nurse obtained orders to administer and discontinue medications for one (Patient #3) of seven patients. Findings: Patient #3 A plan of care dated 05/26/21 to 07/24/21 showed a primary diagnosis of pressure ulcer of other site stage II. A skilled nurse assessment dated 05/27/21 documented the use of "Bactroban" during wound care. A skilled nurse assessment dated 05/31/21 documented the use of "Muprocin" during wound care. A review of the electronic medical record showed no physician orders for the use of "Bactroban" or "Muprocin". On 06/09/21 at 2:25 pm, Staff A stated there was no order to for "Bactroban" or "Muprocin" for Patient #3.

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 the agency's policies and procedures for all agency patients and employees during calendar years of 2019 and 2020. Findings: A review of Governing Body minutes for calendar years of 2019 and 2020 showed no review/revision of current policy and procedure or approval of new policies and procedures. On 06/09/21 at 2:27 pm, Staff A reported governing body minutes for calendar years 2019 and 2020 did document a review or revision of policy and procedures.