Every finding on record at Choice Home Health Care, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 07/02/25 to 07/03/25. 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 included current employee contact information for the agency for all patients and 51 employees. Findings: A review of administrative records showed an Emergency Preparedness Communication Plan did not include contact information for eight of 51 current employees for the agency. On 07/03/25 at 11:30 a.m., Staff D stated the Emergency Preparedness Communication Plan was not updated to include contact information for all of the current employees for the agency.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted in 05/12/23 to 12/31/23 and calendar year 2024 for all patients and 51 employees. Findings: A review of emergency preparedness administrative records showed: · No emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for the Oklahoma City and Altus locations and showed one activation event for the Enid and Clinton locations from 05/15/23 to 12/31/23. · No emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for the Altus and Enid locations and showed one activation event for the Clinton location for calendar year 2024. On 07/03/25 at 11:50 a.m., Staff D stated the agency did not have the required emergency preparedness disaster table-top exercises, drills, community drills or plan activation events from 05/12/23 to 12/31/23 and in calendar year 2024.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with complaint # 115063 at the agency from 07/02/25 to 07/03/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as a contact person for administrative issues, and Staff B, C and D were identified as additional contact people for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff C, D and J. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary notice eMR electronic medical record HHCOC home health change of care OT occupational therapy PICC peripherally inserted central catheter PT physical therapy POC Plan of Care SN skilled nurse SOC start of care

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were advised orally and in writing of charges for services before care is initiated for 20 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and #20) of 20 patients. Findings: A review of the patient information admission packet given to patients and/or their caregiver at the time of admission to the agency showed no written documentation of charges for services and the agency’s standardized consent form documented no reference to oral advisement of charges for services. On 07/03/25 at 12:30 p.m., Staff D stated the agency was not aware it needed to advise or provide a written statement of charges for services to the patients.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure notification to the physician prior to discharge for three (Patients #17 and #18) of 20 patients. Findings: Patient #17 A review of the clinical records showed the patient was discharged from the agency on 03/04/25 for denial of services by the payor source and showed no communication or coordination of care with the ordering medical provider to notify the patient was being discharged from home care services. Patient #18 A review of the clinical records showed the patient was discharged from the agency on 06/27/25 for denial of services by the payor source and showed no communication or coordination of care with the ordering medical provider to notify the patient was being discharged from home care services. On 07/03/25 at 2:25 p.m., Staff D stated the agency did not communicate with the ordering medical provider that the patient was being discharged from the agency prior to the discharge for patients #17 and #18.

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 or home health change of care notices prior to discharge from agency services were provided to three (Patients #17, 18 and #20) of 20 patients. Findings: Patient #17 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 03/04/25 for denial of services by the payor source. Patient #18 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 06/27/25 for denial of services by the payor source. Patient #20 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 02/18/25 for non-payment (write off) for services. On 06/26/25 at 2:40 p.m., Staff D stated there were no ABN of HHCOC notices in the clinical records for patients #17, 18 and #20.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial assessment (evaluation) was conducted within 48 hours (2 days) of referral for two (Patients #1 and #2) of 20 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 09/09/24 and the initial assessment (evaluation) occurred on 09/13/24 (4 days). Documentation showed no patient refusal of initial assessment (evaluation), no physician notification of a delay in initial assessment (evaluation) and no change in orders. On 07/03/25 at 12:40 p.m., Staff D stated the initial assessment (evaluation) should have been conducted by 09/11/24. Patient #2 A review of the clinical record showed the agency received referral information on 05/07/23 and the initial assessment (evaluation) occurred on 05/11/23 (4 days). Documentation showed no patient refusal of initial assessment (evaluation), no physician notification of a delay in initial assessment (evaluation) and no change in orders. On 07/03/25 at 12:42 p.m., Staff D stated the initial assessment (evaluation) should have been conducted by 05/09/23.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a transfer summary for one (Patient #4) of 20 patients. Findings: Patient #4 A review of the clinical record showed the patient was transferred from the agency to in-patient hospital services on 06/12/25 and showed no transfer summary. On 07/03/25 at 2:34 p.m., Staff C stated patient #4 did not have a transfer summary from 06/12/25.

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 a SN intervention last completed and/or next intervention due date for one (Patient #14) of 20 patients. Findings: Patient #14 A review of the POC dated 01/11/25 to 03/11/25 showed orders for SN to assess and measure the patient’s neurological status using the Karnofsky scale every four weeks. The POC did not document the last date conducted or the next date the SN intervention was due. SN visit notes dated 01/11/25, 01/17/25, 01/21/25 and 01/24/25 showed no Karnofsky scale assessment. The SN visit notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/03/25 at 2:00 p.m., Staff D stated the POC should have indicated a last date conducted or the next date the SN intervention was due.

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 a physician order for SN to discontinue a PICC line for one (Patients #9) of 20 patients. Findings: Patient #9 A review of the POC dated 05/23/25 to 07/21/25 showed no physician orders for SN to discontinue a PICC line. A review of the clinical record showed a SN visit note dated 05/28/25 documented that the PICC line was discontinued. The clinical record showed no physician notification and no changes in orders. On 07/03/25 at 1:35 p.m., Staff D stated the patient’s clinical record showed no physician notification and no order to discontinue the PICC line.

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: 1. Coordination of care with the physician after physical therapy evaluation to establish a treatment plan and visit frequency for four (Patients #5, 8, 13 and #14) of 20 patients. 2. Coordination of care with the physician after occupational therapy evaluation to establish a treatment plan and visit frequency for one (Patient #8) of 20 patients. 3. Coordination of care with the physician after continued heart rate and blood pressure reporting parameter alerts were auto faxed through the eMR system for one (Patient #5) of 20 patients. Findings: Patient #5 A review of the POC dated 05/15/25 to 07/13/25 showed orders for PT evaluation (one time a week for one week, week of 05/27/25) and orders for SN to assess and report vital signs outside of reporting parameters to the physician every visit. Physicians ordered reporting parameters are heart rate less than 58 beats per minute or greater than 100; and diastolic blood pressure less than 50 and a systolic blood pressure greater than 150. A PT evaluation dated 05/29/25 showed a recommended PT visit frequency of two times a week for four weeks. Documentation showed PT visits were conducted 06/02/25, 06/04/25, 06/09/25, 06/11/25, 06/16/25 and 06/18/25. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. SN visit notes dated: · 05/27/25 showed a heart rate of 52 · 06/11/25 a diastolic blood pressure of 48 · 06/24/25 heart rate of 52 · 06/30/25 a heart rate of 104. Documentation showed the heart rate and blood pressure levels outside of the reporting parameters were auto faxed through the eMR system but showed no follow up communication or coordination of care with the physician for continued vital signs outside of reporting parameters and showed no change in physician orders. On 07/03/25 at 1:15 p.m., Staff D stated: 1. PT should have contacted the physician and documented coordination of care and a verbal order for the PT treatment plan and visit frequency. 2. SN should have followed up with the physician when the vital sign readings continued to be outside of the reporting parameters. Patient #8 A review of the POC dated 06/05/25 to 08/03/25 showed orders for PT evaluation (one time a week for one week, week of 06/08/25), and OT evaluation (one time a week for one week, week of 06/08/25). A PT evaluation dated 06/16/25 showed a PT visit frequency of two times a week for four weeks. Documentation showed PT visits were conducted 06/20/25, 06/26/25 and on 06/28/25. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 06/13/25 showed an OT visit frequency of one time a week for one week, two times a week for three weeks, then one time a week for one week. Documentation showed no OT visits were conducted between 06/15/25 and 06/30/25. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 07/03/25 at 1:30 p.m., Staff D stated PT and OT should have contacted the physician and documented coordination of care and a verbal order for the PT and OT treatment plans and visit frequencies. Patient #13 A review of the POC dated 04/21/25 to 06/19/25 showed orders for PT evaluation (one time a week for one week, week of 04/27/25). A PT evaluation dated 04/30/25 showed a recommended PT visit frequency of two times a week for four weeks. Documentation showed PT visits were conducted 05/01/25, 05/07/25, 05/09/25 and 05/12/25. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. On 07/03/25 at 1:55 p.m., Staff D stated PT should have contacted the physician and documented coordination of care and a verbal order for the PT treatment plan and visit frequency. Patient #14 A review of the POC dated 01/11/25 to 03/11/25 showed orders for PT evaluation (one time a week for one week, week of 01/12/25). A PT evaluation dated 01/15/25 showed a PT visit frequency of two times a week for four weeks. Documentation showed PT visits were conducted 01/17/25 and a PT missed visit on 01/20/25. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. On 07/03/25 at 2:00 p.m., Staff D stated PT should have contacted the physician and documented coordination of care and a verbal order for the PT treatment plan and visit frequency.

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. SN conduction of urinary catheter change for two (Patients #3 and #16) of 20 patients. 2. SN visits completed visits as ordered for two (Patients #4 and #20) of 20 patients. 3. SN feeding tube placement checks and patient’s weight monitoring every visit as ordered for one (Patient #8) of 20 patients. 4. PT visits completed as ordered for one (Patient #8) of 20 patients. 5.Ankle circumference measurements as ordered for one (Patient #13) of 20 patients. 6. OT evaluation for one (Patient #18) of 20 patients. Findings: Patient #3 A review of the POC dated 05/31/25 to 07/29/25 showed orders for SN to conduct urinary catheter change every four-week, due week of 06/15/25. SN visit notes dated 06/09/25, 06/11/25, 06/13/25, 06/16/25, 06/18/25 and 06/20/25 showed no urinary catheter change was conducted. The SN visit notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/03/25 at 12:45 p.m., Staff D stated the SN should have followed the POC and changed the urinary catheter as ordered or documented why it was not changed. Patient #4 A review of the POC dated 05/28/25 to 07/26/25 showed orders for SN visits two times a week for one week, then three times a week for eight weeks. During the week of 05/28/25 to 05/31/25 a SN visit was conducted on 05/28/25 (two visits ordered, one visit conducted). The documentation showed no patient refusal of care, no physician notification and no changes in orders. On 07/03/25 at 1:00 p.m., Staff D stated SN visits should be conducted as ordered on the POC. Patient #8 A review of the POC dated 06/05/25 to 08/03/25 showed orders for SN to monitor the patient’s weight and check feeding tube placement every visit and PT to evaluate one time a week for one week, week of 06/08/25. SN visit notes dated: · 06/13/25 showed no feeding tube placement check and no weight monitoring · 06/16/25 showed no feeding tube placement check · 06/20/25 showed no feeding tube placement check and no weight monitoring · 06/23/25 showed no feeding tube placement check and no weight monitoring · 06/27/25 showed no feeding tube placement check and no weight monitoring The SN visit notes showed no patient refusal of care, no physician notification and no changes in orders. A review of a PT evaluation dated 06/16/25 showed the evaluation was not conducted as ordered during the week of 06/08/25 (8 days). The evaluation showed no patient refusal of care, no physician notification and no change in orders. On 07/03/25 at 1:30 p.m., Staff D stated: 1. The SN should have assessed the patient’s feeding tube placement and weight each visit. 2. The PT evaluation should have been conducted as ordered on the POC. Patient #13 A review of the POC dated 04/21/25 to 06/19/25 showed orders for SN to measure the patient’s ankle circumference every visit. SN visit notes dated 04/21/25, 04/28/25, 05/05/25 and 05/12/25 showed no ankle circumference measurements. The SN visit notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/03/25 at 1:55 p.m., Staff D stated the SN should have measured the patient’s ankle circumference every visit as ordered on the POC. Patient #16 A review of the POC dated 12/24/24 to 02/21/25 showed orders for SN to conduct urinary catheter change every three weeks, due week of 12/29/24. SN visit note dated 12/30/24 documented a urinary catheter change. SN visit notes dated 01/23/25, 01/28/25 and 02/06/25 showed no urinary catheter change was conducted. The SN visit notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/03/25 at 2:10 p.m., Staff D stated the SN should have followed the POC and changed the urinary catheter as ordered or documented why it was not changed. Patient #20 A review of the POC dated 12/21/24 to 02/18/25 showed orders for SN visits one time a week for one week, then one time every two weeks for six weeks. During the week of 01/26/25 to 02/01/25 no SN visit was conducted (one visit ordered, no visit conducted). The documentation showed no patient refusal of care, no physician notification and no changes in orders. On 07/03/25 at 2:30 p.m., Staff D stated SN visits should be conducted as ordered on the POC. Patient #18 A review of the POC dated 03/07/25 to 05/06/25 showed orders for OT to evaluate one time a week for one week, week of 03/06/25. An OT evaluation dated 06/18/25 was reviewed. The clinical record showed the OT evaluation was delayed due to no OT staff available in the patient’s area. The clinical record showed no patient refusal of the OT evaluation from week of 03/06/25, no physician notification and no changes in orders. On 07/03/25 at 2:25 p.m., Staff D stated the OT evaluation should have been conducted as ordered on the POC.

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 eight (Patients #1, 2, 3, 4, 6, 7, 10 and #11) of 20 patients. Findings: Patient #1 A review of the clinical record showed a SN visit note dated 05/21/25 was incomplete until 05/30/25 (9 days). On 07/03/25 at 12:40 p.m., Staff D stated non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit. Patient #2 A review of the clinical record showed a SN visit note dated 05/07/25 was incomplete until 05/11/25 (4 days). On 07/03/25 at 12:42 p.m., Staff D stated non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit. Patient #3 A review of the clinical record showed a SN visit note dated 06/25/25 was blank (incomplete) as of the 07/02/25 review date (7 days). On 07/03/25 at 12:45 p.m., Staff D stated: 1. Non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit. 2. The visit will show as scheduled/not completed until the documentation is completed in the eMR system. Patient #4 A review of the clinical record showed a SN visit note dated 05/28/25 was incomplete until 06/02/25 (5 days). On 07/03/25 at 1:00 p.m., Staff D stated non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit. Patient #6 A review of the clinical record showed a SN visit note dated 06/05/25 was incomplete until 06/08/25 (3 days). On 07/03/25 at 1:20 p.m., Staff D stated non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit. Patient #7 A review of the clinical record showed SN visit notes dated: · 04/30/25 was incomplete until 05/20/25 (20 days) · 05/02/25 was incomplete until 05/12/25 (10 days) · 05/09/25 was incomplete until 05/12/25 (3 days) On 07/03/25 at 1:22 p.m., Staff D stated: 1. Non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit. 2. The SN was placed on an action plan and was later terminated for documentation problems. Patient #10 A review of the clinical record showed SN visit notes dated: · 05/09/25 was incomplete until 05/15/25 (6 days) · 05/19/25 was incomplete until 05/25/25 (6 days) On 07/03/25 at 1:22 p.m., Staff D stated: 1. Non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit. 2. The SN was placed on an action plan for documentation problems. Patient #11 A review of the clinical record showed a SN visit note dated 06/26/25 was incomplete until 06/30/25 (4 days). On 07/03/25 at 1:52 p.m., Staff D stated non-OASIS SN visit notes are to be completed in the eMR by the next day after the date of the visit.

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 interviews, the agency failed to ensure a complete transfer/discharge summary was provided to the receiving service provider for eight (Patients #5, 13, 14, 15, 16, 17, 19 and #20) of 20 patients. Findings: Patient #5 A review of the clinical record showed an inpatient hospital transfer date of 05/20/25. The clinical record showed no transfer summary was provided to the inpatient hospital service provider. Patient #13 A review of the clinical record showed an inpatient hospital transfer date of 05/19/25. The clinical record showed no transfer summary was provided to the inpatient hospital service provider. Patient #14 A review of the clinical record showed an inpatient hospital transfer date of 01/28/25. The clinical record showed no transfer summary was provided to the inpatient hospital service provider. Patient #15 A review of the clinical record showed an inpatient hospital transfer date of 05/16/25. The clinical record showed no transfer summary was provided to the inpatient hospital service provider. Patient #16 A review of the clinical record showed a discharge date of 02/18/25 to hospice services. The clinical record showed no discharge summary was provided to the hospice service provider and was provided to the physician on 03/18/25 (28 days later). Patient #17 A review of the clinical record showed a discharge date of 03/04/25. The clinical record showed the discharge summary was provided to the physician on 03/10/25 (6 days later). Patient #19 A review of the clinical record showed a discharge date of 05/21/25 to nursing home services. The clinical record showed no discharge summary was provided to the nursing home service provider and was provided to the physician on 05/28/25 (7 days later). Patient #20 A review of the clinical record showed a discharge date of 02/18/25. The clinical record showed the discharge summary was provided to the physician on 03/13/25 (23 days later). On 07/03/25 at 2:40 p.m., Staff C stated: 1. The agency had no way of showing the transfer/discharge summaries were provided to the receiving service providers. 2. The physician should receive a copy of a discharge summary within 5 days from the date we become aware of the patient’s transfer or discharge.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 08/16/22 to 08/18/22. 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 08/16/22 to 08/18/22. An entrance conference was conducted with Staff A, B and C. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative issues and Staff C was identified as the contact person for clinical issues during the survey. Findings were discussed during an informal exit conference with Staff A, B, C, D, E and F. Standard level deficiencies were cited as a result of the survey. Glossary: POC plan of care PIP Performance Improvement Project PT Physical Therapy PRN pro re nata [for the present matter: as needed] QAPI Quality Assessment and Performance Improvement SN skilled nurse ST Speech Therapy

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 (Patients #6 and #8) of 13 patients. Findings: Patient #6 A review of a plan of care dated 07/25/22 to 09/22/22 showed a SN visit frequency of one time a week for nine weeks for SN to assess patient weight and report change in weight to the physician. Documentations showed: 1. during SN visits dated 07/27/22 the patient’s weight was 135.8 pounds and the physician’s office was auto-faxed by the electronic medical record system on 08/03/22 with no response or verification of receipt and 2. on 08/03/22 the patient’s weight was 141 pounds, 4.8 pounds heavier than the week before and the physician’s office was auto-faxed by the electronic medical record system on 08/05/22 with no response or verification of receipt. Documentations showed no follow up communication attempts with the physician to notify that patient experienced continued weight gain and no changes in orders. On 08/18/22 at 8:35 a.m., Staff C stated there was no follow up communications with the physician that patient experienced continued weight gain. Patient #8 A review of a plan of care dated 07/10/22 to 09/07/22 showed a SN visit frequency of one time a week for nine weeks for SN to assess patient weight and report change in weight to the physician. Documentations showed: 1. during SN visits dated 07/25/22 the patient’s weight was 116.8 pounds and the physician’s office was auto-faxed by the electronic medical record system on 07/26/22 with no response or verification of receipt. 2. on 08/01/22 the patient’s weight was 124 pounds, 8.8 pounds heavier than the week before and the physician’s office was auto-faxed by the electronic medical record system on 08/02/22 with no response or verification of receipt. 3. on 08/10/22 the patient’s weight was 125.8 pounds, 1.8 pound heavier than the two weeks before and the physician’s office was auto-faxed by the electronic medical record system on 08/12/22 with no response or verification of receipt. Documentations showed no follow up communication attempts with the physician to notify that patient experienced continued weight gain and no changes in orders. On 08/18/22 at 8:51 a.m., Staff C stated there was no follow up communications with the physician that patient experienced continued weight gain.

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 data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: An agency policy titled, "Quality Assessment Performance Improvement Program," stated the agency will implement a performance program that monitors performance through data collection, analyzing current performance and improves and sustains improved performance. The data will measure, analyze and track quality indicators, patient events and other aspects of performance that enable processes of care, services and operations. The agency will collect data related to patient care outcomes, complaints and incidents, infection control activities and errors. The QAPI committee meetings will be documented. A review of administrative records showed no review and analysis of data collection activities utilized in the agency's QAPI Program for calendar years 2020, 2021 and 01/01/22 to 08/18/22. Additional administrative records were requested. On 08/18/22 at 10:45 a.m., Staff C stated: 1. Program improvement data was not available for calendar year 2020 and; 2. The agency had no analysis of data collected that showed improved quality of patient care for calendar years 2020, 2021 and 01/01/22 to 08/18/22.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of ongoing patient centered QAPI Program activities for all patients and employees. Findings: An agency policy titled, :Quality Assessment Performance Improvement Program," stated the agency will implement a performance program that monitors performance through data collection, analyzing current performance and improves and sustains improved performance. The data will measure, analyze and track quality indicators, patient events and other aspects of performance that enable processes of care, services and operations. The QAPI committee meetings will be documented. A review of administrative records showed no documentation of ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar year 2020; showed no 2nd quarter, 3rd quarter or 4th quarter activities for calendar year 2021 and no QAPI activities for 01/01/22 to 08/18/22. Additional administrative records were requested. On 08/18/22 at 10:45 a.m., Staff C stated: The agency had no documentation which showed QAPI program activities, including meeting minutes for calendar year 2020, 2nd, 3rd or 4th quarters calendar year 2021 and no QAPI activities for 01/01/22 to 08/10/22 and;Agency QAPI meetings were only conducted two times a year.

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 initiation and review of a PIP through their QAPI Program for all patients and employees. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs in calendar year 2021 and 01/01/22 to 08/18/22. Additional administrative records were requested. On 08/18/22 at 10:45 a.m., Staff C stated the agency had no PIP activities documented for calendar year 2021 and 01/01/22 to 08/18/22.

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 a patient centered QAPI Program activities for all patients and employees. Findings: An agency policy titled, "Quality Assessment Performance Improvement Program," stated agency management is responsible for the development, implementation, maintenance and evaluation of a QAPI program that is effective, ongoing, agency wide and data driven. Performance measures will be implemented to address priorities for improved quality of care and patient safety and all improvement actions will be evaluated. The agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency and no governing body oversite of the QAPI program for the agency for calendar years 2020, 2021 and no QAPI activities for 01/01/22 to 08/18/22. Additional administrative records were requested. On 08/18/22 at 11:00 a.m., Staff A stated the agency had no governing body documentation which showed oversite of the conduction of QAPI program activities for calendar years 2020, 2021 and 01/01/22 to 08/18/22.

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 surveillance data was included in QAPI activities for all patients and employees. Findings: A review of administrative records showed no ongoing infection control surveillance data reported through the QAPI program for the agency for calendar years 2020, 2021 and 01/01/22 to 08/18/22. Additional administrative records were requested. On 08/18/22 at 10:45 a.m., Staff C stated no infection surveillance activities were reported through the agency's QAPI program for calendar years 2020, 2021 and 01/01/22 to 08/18/22.

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 for: SN to conduct visit frequency as ordered by the physician for five (Patients #1, 4, 7, 8 and #9) of 13 patients;SN to conduct wound site assessment every visit for one (Patient #3) of 13 patients;SN to conduct weight assessment every visit and notify the physician of change in weight outside of reporting parameters for two (Patients #4 and #8) of 13 patients;PT to conduct visit frequency as ordered by the physician for two (Patients #6 and #10) of 13 patients;ST to conduct visit frequency as ordered by the physician for one (Patient #10) of 13 patients and;SN to conduct pain assessment every visit and notify the physician of pain level outside of reporting parameters for one (Patient #10) of 13 patients. Findings: Patient #1 A review of a plan of care dated 06/15/22 to 08/13/22 showed a SN visit frequency of one time a week for one week, two times a week for one week, then one time a week for seven weeks. A physician's order dated 08/04/22 showed documentation of SN to conduct an extra SN visit to assess the patient’s right side abdominal fold. Documentation showed no extra (PRN) SN visit was conducted on 08/04/22 or during the rest of the Medicare week through 08/07/22. Documentation showed no patient or caregiver refusal of a visit, no physician notification of a missed visit and no changes in orders. On 08/18/22 at 8:10 a.m., Staff C stated no SN visit was conducted 08/04/22 through 08/06/22 on patient #1. Patient #3 A review of a plan of care dated 07/15/22 to 09/12/22 showed a SN visit frequency of one time a week for nine weeks for SN to assess wound sites to bilateral lower extremities weekly. During SN visits dated 08/12/22 and on 08/16/22 documentation showed no assessment of the wound sites. Documentation showed no patient or caregiver refusal of wound site assessment, no physician notification and no changes in orders. On 08/18/22 at 8:19 a.m., Staff C stated the SN should have conducted and documented assessment of the wound sites during the 08/12/22 and 08/16/22 SN visits for patient #3. Patient #4 A review of a plan of care dated 06/09/22 to 08/07/22 showed a SN visit frequency of one time a week for one week, then three times a week for eight weeks for SN to perform wound care and assess patient weight and report change in weight to the physician. During SN visits dated 06/14/22, 06/15/22, 06/21/22, 06/22/22, 06/24/22, 06/27/22, 07/01/22, 07/04/22, 07/06/22, 07/08/22, 07/11/22, 07/13/22, 07/15/22, 07/18/22, 07/20/22, 07/22/22, 07/25/22, 07/27/22, 07/29/22, 08/01/22, 08/03/22 and on 08/05/22 documentation showed no assessment of the patient’s weight. Documentation showed no patient or caregiver refusal of weight assessment, no physician notification and no changes in orders. Documentation showed during the week of 06/12/22 to 06/18/22 SN visits were conducted on 06/14/22 and on 06/15/22 (three visits ordered, two visits conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification of a missed visit and no changes in orders. On 08/18/22 at 8:27 a.m., Staff C stated: The patient’s weight should have been assessed and documented every visit as ordered and;SN visit frequency should have been three visits during the week of 06/12/22 to 06/18/22 for patient #4. Patient #6 A review of a plan of care dated 07/25/22 to 09/22/22 showed a PT visit frequency of one time a week for one week, then two times a week for three weeks and one time a week for one week. Documentation showed the PT evaluation was conducted on 07/28/22 and no PT visits were conducted after the evaluation visit. Documentation showed no patient or caregiver refusal of a PT visits, no physician notification and no changes in orders. On 08/18/22 at 8:35 a.m., Staff C stated no PT visits were conducted during the weeks from 07/31/22 through 08/13/22 on patient #6. Patient #7 A review of a plan of care dated 06/28/22 to 08/26/22 showed a SN visit frequency of one time a week for nine weeks. A SN missed visit note dated 07/23/22 showed the SN visit was missed because the nurse was sick (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 08/18/22 at 8:45 a.m., Staff C stated no SN visit was conducted during the week of 07/17/22 through 07/23/22 on patient #7. Patient #8 A review of a plan of care dated 07/10/22 to 09/07/22 showed a SN visit frequency of one time a week for nine weeks for SN to assess patient weight and report change in weight to the physician. During the week of 07/17/22 to 07/23/22 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. During SN visit dated 08/05/22 documentation showed no assessment of the patient’s weight. Documentation showed no patient or caregiver refusal of weight assessment, no physician notification and no changes in orders. Documentations showed during SN visits dated 08/12/22 and on 08/15/22 the patient’s weight was 125 pounds. Documentation showed no physician notification and no changes in orders. On 08/18/22 at 8:51 a.m., Staff C stated: No SN visit was conducted during the week of 07/17/22 through 07/23/22 on patient #8 and documentation showed the SN visit was missed due to the nurse was sick;No assessment of the patient’s weight was conducted as ordered during the 08/05/22 SN visit and;The patient’s weight on 08/12/22 and on 08/15/22 SN visits should have been reported to the physician for patient #8. Patient #9 A review of a plan of care dated 07/14/22 to 09/11/22 showed a SN visit frequency of one time a week for one week, then one time a week every other week for six weeks. During the week of 07/31/22 to 08/06/22 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 08/18/22 at 9:01 a.m., Staff C stated no SN visit was conducted during the week of 07/31/22 through 08/06/22 on patient #9. Patient #10 A review of a plan of care dated 07/01/22 to 08/29/22 showed a PT evaluation the week of 07/03/22 to 07/09/22. Documentation showed the PT evaluation was conducted on 07/12/22. Documentation showed no patient or caregiver refusal of a PT evaluation, no physician notification and no changes in orders. Documentation showed a ST evaluation week of 07/03/22 to 07/09/22. Documentation showed the ST evaluation was conducted on 07/13/22. Documentation showed no patient or caregiver refusal of a ST evaluation, no physician notification and no changes in orders. Documentation showed a SN visit frequency of one time a week for nine weeks for SN to assess patient pain and report pain level greater than three to the physician. During SN visit dated 08/05/22, the patient reported a pain level greater than four. Documentations showed no physician notification and no changes in orders. On 08/18/22 at 9:02 a.m., Staff C stated: The PT evaluation was not conducted during the week from 07/03/22 through 07/09/22 as ordered;The ST evaluation was not conducted during the week from 07/03/22 through 07/09/22 as ordered and;The SN did not report the patient pain level of four on 08/05/22 to the physician for patient #6.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure PT visit notes were completed for one (Patient #3) of 13 patients. Findings: An agency policy, titled "Documentation Practices," stated clinical documentation must be incorporated into the patient medical record within seven days of the date of service provision. Patient #3 A review of a plan of care dated 07/15/22 to 09/12/22 showed a PT visit frequency of one time a week for one week, then two times a week for four weeks. PT visits conducted on 07/28/22, 07/29/22, 08/01/22, 08/04/22 and on 08/08/22 showed no documentation of the visits. Documentation showed no patient or caregiver refusal of the PT visits, no physician notification and no changes in orders. On 08/18/22 at 8:19 a.m., Staff C stated: The PT visit notes for 07/28/22, 07/29/22, 08/01/22, 08/04/22 and 08/08/22 were attached to the patient’s clinical record on 08/17/22 (one day after the clinical record review) and;The visit notes should have been submitted and attached to the patient’s clinical record within 7 days from the date of the visit.

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 transfer/discharge summary was provided to the receiving service provider for three (Patient #11, 12 and #13) of 13 patients. Findings: Patient #11 A review of the clinical record documented transfer from the agency on 08/01/22 to residential Long Term Care services with subsequent discharge from agency services on 08/12/22. Documentation showed no transfer/discharge summary was provided to the residential Long Term Care service provider at the time of transfer or discharge from agency services. Additional documentation was requested. On 08/18/22 at 10:25 a.m., Staff C stated no transfer/discharge summary was provided the residential Long Term Care service provider for patient #11. Patient #12 A review of the clinical record documented discharge from the agency on 07/08/22 to Hospice services. Documentation showed no discharge summary was provided to the Hospice service provider at the time of discharge from agency services. Additional documentation was requested. On 08/18/22 at 10:25 a.m., Staff C stated no discharge summary was provided the Hospice service provider for patient #12. Patient #13 A review of the clinical record documented transfer from the agency on 06/17/22 to in-patient hospital services. Documentation showed no transfer summary was provided to the in-patient hospital service provider at the time of transfer from agency services. Additional documentation was requested. On 08/18/22 at 10:25 a.m., Staff C stated no transfer summary was provided the residential Long Term Care service provider for patient #13.