Every finding on record at Cherokee Nation Home Health Services, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 03/19/25 to 03/20/25. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan showed employee contact information for the agency for 465 patients and 51 employees. Findings: A review of Emergency Preparedness records showed no Emergency Preparedness Communication Plan which included current employee contact information for the agency. On 03/20/25 at 12:30 p.m., Staff A stated the Emergency Preparedness Communication Plan did not include contact information for current employees of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with a complaint (#109982) at the agency from 03/19/25 to 03/20/25. An entrance conference was conducted with Staff A, B and C. The survey process was explained. Questions were answered. Staff A was identified as a contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B and D. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary EMR electronic medical record HHA Home Health Agency HHCOC home health change of care MSW medical social work OASIS outcome assessment [system] information set PT physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse SOC start of care

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 an advance beneficiary notice or HHCOC notice was provided to two (Patients #14 and #15) of 17 patients. Findings: Patient #14 A review of the clinical record showed a SOC date of 08/15/24. Documentation showed no physician order for discharge, no advance notice of discharge, no home health change of care notice, and no physician communications prior to the patient’s discharge from the agency on 12/30/24 for no insurance authorization for services. On 03/20/25 at 1:27 p.m., Staff B stated there was no ABN, HHCOC notices or physician communications in the clinical record prior to the patient being discharged from the agency for no insurance authorization for services. Patient #15 A review of the clinical record showed a SOC date of 12/30/23. Documentation showed no physician order for discharge, no advance notice of discharge, no home health change of care notice, and no physician communication prior to the patient’s discharge from the agency on 11/25/24 for no insurance authorization for services. On 03/20/25 at 1:28 p.m., Staff B stated there were no ABN, HHCOC notices or physician communications in the clinical record prior to the patient being discharged from the agency.

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 a medication profile was updated for ordered medications for one (Patient #5) of 17 patients. Findings: Patient #5 A review of the clinical record showed a POC dated 02/11/25 to 04/11/25. A SN visit note dated 02/26/25 documented the patient reported the physician ordered Keflex 500 mg two times a day for five days to treat a urinary tract infection. Documentation showed no physician notification for order, no update to the medication profile, no follow up review by the SN, and no follow-up with the physician. On 03/20/25 at 1:05 a.m., Staff B stated the medication profile showed no update to the medication profile and no follow up review by the SN.

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 QAPI quality indicator data to improve program effectiveness, quality of patient care and overall program improvement for 465 patients and 51 employees. Findings: A review of administrative QAPI records for 01/01/23 to 12/31/23 and 01/01/24 to 12/31/24 showed no quality indicator data collection sources from OASIS reporting utilized in the analysis of data in the agency's QAPI Program. On 03/20/25 at 12:30 p.m., Staff A stated QAPI program documentation showed no collection or analysis of OASIS reporting data.

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 the Infection Control Program surveillance data was included in QAPI program activities for 01/01/23 to 12/31/23 and 01/01/24 to 12/31/24 for 465 patients and 51 employees. Findings: A review of an administrative policy titled; "Quality Assurance and Performance Improvement (10.1.5)", stated data collection will include infection prevention and control, surveillance/ identification/ reporting/ prevention system for the agency as a part of Quality Assurance reporting. A review of QAPI administrative records showed no infection control surveillance data in the QAPI program for 01/01/23 to 12/31/23 and 01/01/24 to 12/31/24. On 03/20/25 at 12:30 p.m., Staff A stated there was no infection surveillance activities shown in QAPI records for 01/01/23 to 12/31/23 and 01/01/24 to 12/31/24.

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: 1. PT visits as ordered for one (Patient #4) of 17 patients. 2. SN visits as ordered for one (Patient #6) of 17 patients. 3. Assess and monitor patients’ weights as ordered for two (Patients #6 and #9) of 17 patients. 4. Report to physician patient’s pain level greater than 8 of 10 to the physician for one (Patients #16) of 17 patients. Findings: Patient #4 A review of the POC dated 01/18/25 to 03/18/25 showed orders for PT visit frequency and duration of two times a week for eight weeks, then one time a week for one week. Documentation showed during the week of 02 16/25 to 02/22/25 a PT visit dated 02/20/25 (two visits ordered, one visit conducted). Documentation showed no physician notification and no changes in orders. On 03/20/25 at 1:00 p.m., Staff B stated the PT should have conducted two visits during the week of 02 16/25 to 02/22/25. Patient #6 A review of the POC dated 02/12/25 to 04/12/25 showed orders for SN visit frequency and duration of one time a week for nine weeks to assess, monitor and report the patient’s pain level (greater than 8 of 10) and weight (3 pounds in 24 hours and 5 pounds in one week) outside of reporting parameters as ordered by the physician. Documentation showed during SN visit on 02/20/25 no weight assessment and on 02/27/25, 03/15/25 and on 03/10/25 showed no pain assessments. Documentation showed no physician notification and no changes in orders. On 03/20/25 at 1:06 p.m., Staff B stated the SN should have conducted weight and pain assessments as ordered by the physician. Patient #9 A review of the POC dated 02/21/25 to 04/21/25 showed orders for SN visit frequency and duration of one time a week for eight weeks to assess, monitor and report the patient’s weight (3 pounds in 24 hours and 5 pounds in one week) outside of reporting parameters as ordered by the physician. Documentation showed during SN visit on 03/06/25 no weight assessment. Documentation showed no physician notification and no changes in orders. On 03/20/25 at 1:12 p.m., Staff B stated the SN should have conducted weight assessment as ordered by the physician. Patient #16 A review of the POC dated 11/28/25 to 01/15/25 showed orders for SN frequency and duration of one time a week for nine weeks to assess the patient’s pain level and instruct pain management interventions and report patient’s reported pain levels greater than 8 of 10 every visit. Documentation showed SN visits dated 11/27/24 reported a pain level of 10 of 10, 12/09/24 reported a pain level of 9, 12/16/24 reported a pain level of 10 of 10, 12/23/24 reported a pain level of 9 of 10 and on 01/06/25 reported a pain level of 9 of 10. Documentation showed no physician notification and no changes in orders. On 03/20/25 at 11:30 a.m., Staff B stated the SN should have contacted the physician and reported the patient’s pain level during the visits.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for 01/01/23 to 12/31/23 and 01/01/24 to 12/31/24 for all patients and employees. Findings: A review of administrative QAPI records showed no multi-disciplined skilled professional staff (PT, OT, ST or MSW in addition to SN) participation in QAPI activities for 01/01/23 to 12/31/23 and 01/01/24 to 12/31/24. On 03/20/25 at 12:30 p.m., Staff A stated documentation showed no multi-disciplined skilled professional staff participation in ongoing QAPI program.