Every finding on record at Choice Home Health, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/15/23 to 02/16/23. 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 02/15/23 to 02/16/23. 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 issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A. Standard level deficiencies were cited as a result of the survey. Glossary: HHA Home Health Agency OT Occupational therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure patients’ rights to have completed assessments, participate in the establishment and revision of a plan of care and be informed of disciplines to provide services with expected frequencies of visits for one (Patient #3) of 18 patients. Findings: Patient #3 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 01/14/23 to 03/14/23. Documentation showed no patient/caregiver participation in a comprehensive assessment and establishment of a POC, no physician notification of the conducted comprehensive OASIS assessment on 01/14/23 and documented no physician orders. On 02/16/23 at 2:10 p.m., Staff B stated: 1. Patient #3 had a start of care on 01/14/23 and showed no comprehensive assessment (OASIS) was completed; 2. Did not have a POC (which includes physician orders) for the episode period of 01/14/23 to 03/14/23 and; 3. Received agency services without physician orders.

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 an advance notice of discharge was provided prior to being discharged from the agency for four (Patients #11, 12, 13 and #18) of 18 patients. Findings: Patient #11 A review of the clinical record showed the patient was discharged without a visit (desk discharge) on 09/09/22 for patient refusal of care and showed no documentation of an advance notice of discharge prior to discharge from the agency. Patient #12 A review of the clinical record showed the patient was discharged from the agency on 11/30/22 for lack of funding (Insurance authorization) and showed no documentation of an advance notice of discharge prior to discharge from the agency. Patient #13 A review of the clinical record showed the patient was discharged from the agency on 12/31/22 for lack of funding (Insurance authorization) and showed no documentation of an advance notice of discharge prior to discharge from the agency. Patient #18 Documentation showed the patient was discharged without a visit (desk discharge) on 10/31/22 for unable to meet patient’s needs and showed no documentation of an advance notice of discharge prior to discharge from the agency. On 02/16/23 at 3:15 p.m., Staff B stated Patients #11, 12, 13 and #18 received no advance notice of discharge prior to their discharge from agency services.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Show documentation of the problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services for one (Patient #11) of 18 patients; 2. Educate the patient on potential health outcomes from discontinued HHA care and services for one (Patient #11) of 18 patients; 3. Notify the physician of the patient's behaviors that impeded the HHA from providing care and services for one (Patient #11) of 18 patients. Findings: Patient #11 A review of a plan of care for 07/16/22 to 09/13/22 showed a SN visit frequency of one times a week for nine weeks for SN to assess hypertension and co-morbidities and recognize and intervene to minimize complications from those conditions each visit and to review and instruct on new or changed medications. SN visit notes and communication notes from the certification period of 07/16/22 to 09/13/22 showed no documentation of patient refusal of care. A last SN visit note dated 08/31/22 documented a physical assessment was performed, education related to pain was provided and that there were no issues. Documentation showed no identified problems encountered by the HHA related to behaviors or conditions that impeded the HHA from providing care and services, no communication or education attempts to the patient for potential health outcomes resulting from discontinued HHA care and services, no physician notification of the patient's behaviors and living conditions that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for patient refusal of care prior to the discharge date of 09/09/22. On 02/16/23 at 2:40 p.m., Staff B stated there was no documentation of: 1. Problems encountered by the HHA related to behaviors and conditions that impeded the HHA from providing care and services; 2. Patient education of potential health outcomes from discontinued HHA care and services; 3. Physician notification of the patient's behaviors and living conditions that impeded the HHA from providing care and services.

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 episodic Plan of Care for three (Patients #3, 7 and #10) of 18 patients. Findings: Patient #3 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 01/14/23 to 03/14/23. Documentation showed no physician notification of the conducted comprehensive OASIS assessment (SOC) on 01/14/23 and documented no physician orders. On 02/16/23 at 2:10 p.m., Staff B stated: 1. Patient #3 did not have a POC (physician orders) for the episode period of 01/14/23 to 03/14/23 and; 2. Received agency services without physician orders and; Patient #7 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 02/05/22 to 04/05/23. Documentation showed no physician notification of the conducted comprehensive (recertification) OASIS assessment and documented no physician orders. On 02/16/23 at 2:23 p.m., Staff B stated: 1. Patient #3 did not have a POC (physician orders) for the episode period of 02/05/22 to 04/05/23; 2. Received agency services without physician orders. Patient #10 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 01/21/23 to 03/21/23. Documentation showed no physician notification of the conducted comprehensive (recertification) OASIS assessment and documented no physician orders. On 02/16/23 at 2:35 p.m., Staff B stated: 1. Patient #10 did not have a POC (physician orders) for the episode period of 01/21/23 to 03/21/23 and; 2. Received agency services without physician orders.

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: 1. An individualized patient POC included pain reporting parameters for five (Patients #2, 4, 5, 8 and #9) of 18 patients and; 2. An individualized patient POC included catheter treatment intervention due or last changed date for one (Patient #6) of 18 patients. Findings: Patient #2 A review of a POC dated 01/12/23 to 03/12/23 showed orders for a SN visit frequency of one time a week for nine weeks for SN to assess and teach to properly assess, manage and mitigate pain. Documentation showed no physician pain reporting parameters on the POC. Documentation showed patient pain assessment levels during SN visits dated 01/26/23, 02/02/23, 02/04/23, 02/10/23 and on 02/15/23. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/16/23 at 2:05 p.m., Staff B stated the POC for patient #2 should have included physician pain reporting parameters. Patient #4 A review of a POC dated 01/02/23 to 03/02/23 showed orders for a SN visit frequency of one time a week for two weeks for SN to assess and teach to properly assess, manage and mitigate pain. Documentation showed no physician pain reporting parameters on the POC. Documentation showed patient pain assessment levels during SN visits dated 01/09/23 reported pain level of 3; and on 01/20/23 reported pain level of 2. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/16/23 at 2:15 p.m., Staff B stated the POC for patient #4 should have included physician pain reporting parameters. Patient #5 A review of a POC dated 01/06/23 to 03/06/23 showed orders for a SN visit frequency of one time a week for nine weeks for SN to assess and teach to properly assess, manage and mitigate pain. Documentation showed no physician pain reporting parameters on the POC. Documentation showed patient pain assessment levels during SN visits dated 01/10/23. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/16/23 at 2:17 p.m., Staff B stated the POC for patient #5 should have included physician pain reporting parameters. Patient #6 A review of the POC dated 10/14/22 to 12/12/22 showed orders for SN to conduct assessment and manage catheter treatment intervention every month. Documentation showed no treatment intervention due or last changed date on the POC. Documentation showed SN visits were conducted on 01/02/23 to change the catheter; on 01/13/23 a PRN SN visit was conducted to change the catheter. Subsequent SN visits on 01/24/23, 01/31/23, 02/07/23 and on 02/14/23 showed no catheter treatment intervention was conducted. Documentation showed no patient/caregiver refusal of SN catheter treatment intervention during the SN visits, no physician notifications and no change in orders. On 02/16/23 at 2:20 p.m., Staff B stated the POC for patient #6 should have included catheter treatment intervention due date or last changed date. Patient #8 A review of a POC dated 12/29/22 to 02/26/23 showed orders for a SN visit frequency of one time a week for eight weeks for SN to assess and teach to properly assess, manage and mitigate pain. Documentation showed no physician pain reporting parameters on the POC. Documentation showed patient pain assessment levels during SN visits dated 01/04/23 reported pain level of 4; 01/11/23 reported pain level of 3; 01/18/23 reported pain level of 2; 01/25/23 reported pain level of 3; 02/03/23 reported pain level of 3 and on 02/08/23 reported pain level of 3. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/16/23 at 2:30 p.m., Staff B stated the POC for patient #8 should have included physician pain reporting parameters. Patient #9 A review of a POC dated 01/26/23 to 03/26/23 showed orders for a SN visit frequency of one time a week for one week, three time a week for one week, then two times a week for seven weeks for SN to assess and teach to properly assess, manage and mitigate pain. Documentation showed no physician pain reporting parameters on the POC. Documentation showed patient pain assessment levels during SN visits dated 01/31/23 reported pain level as unable to communicate / crying; 02/02/23 reported pain level as unable to communicate/crying; 02/02/23 reported pain level as unable to communicate/crying; 02/09/23 reported pain level as unable to communicate/crying; and on 02/14/23 reported pain level as unable to communicate/crying. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/16/23 at 2:31 p.m., Staff B stated the POC for patient #8 should have included physician pain reporting parameters.

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 reviews and interview, the agency failed to ensure SN visits were ordered by the physician for two (Patients #7 and #10) of 18 patients. Findings: Patient #7 A review of the clinical record showed no documentation of physician orders for a POC episode period of 02/05/23 to 04/05/23. Documentation showed SN visits were conducted on 02/06/23, 02/08/23, 02/10/23, 02/13/23 and on 02/15/23 (five SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 02/16/23 at 2:23 p.m., Staff B stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN and CHHA visits were conducted without orders for patient #7. Patient #10 A review of the clinical record showed no documentation of physician orders for a POC episode period of 01/21/23 to 03/21/23. Documentation showed SN visits were conducted on 01/24/23 and 02/09/23 (two SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 02/16/23 at 2:35 p.m., Staff B stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN and CHHA visits were conducted without orders for patient #10.

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 #3, 13 and #18) of 18 patients. Findings: Patient #3 A review of an SOC OASIS dated 01/14/23 for episode period of 01/14/23 to 03/14/23 (no documented plan of care) documented a primary diagnosis of bronchitis. A coordination note dated 02/10/23 documented the patient transferred to the emergency room for hospital in patient provider services. Documentation showed no transfer to in patient services, no follow up coordination of care and no physician notification. On 02/16/23 at 2:10 p.m., Staff B stated the physician for patient #3 should have been notified of the patient’s transfer to in patient emergency medical services. Patient #13 A review of a plan of care for 11/11/22 to 01/09/23 documented a primary diagnosis of depressive disorder. Documentation showed the patient was discharged via a desk discharge (no visit) on 12/31/22 for lack of funds (no insurance authorization). Documentation showed no physician notification of the patient’s imminent discharge from the HHA for lack of funds (no insurance authorization) prior to discharge from agency services. On 02/16/23 at 2:40 p.m., Staff B stated the physician for patient #13 should have been notified of the patient’s imminent discharge from agency services prior to the patient’s discharged. Patient #18 A review of a plan of care for 09/20/22 to 11/18/22 documented a primary diagnosis of acute kidney failure. Documentation showed the patient was discharged via a desk discharge (no visit) on 10/21/22 for unable to meet the patients need. Documentation showed physician notification of patient’s ETOH use on 10/07/22 but showed no physician notification of the patient’s imminent discharge from the HHA for cause prior to discharge from agency services. On 02/16/23 at 3:10 p.m., Staff B stated the physician for patient #18 should have been notified of the patient’s imminent discharge from agency services prior to the patient’s discharged.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees. Findings: Administrative records of ongoing patient centered QAPI program for the agency for calendar years 2021 and 2022 were requested. Documentation of governing body meeting minutes dated 01/04/21 and 01/02/22 included statement of: ‘QAPI program was reviewed’; and showed 12 month summary statements of SHP quality indicator data for calendar years 2021 and 2022 were provided. Documentation showed no conduction of patient centered QAPI Program. On 02/16/23 at 4:00 p.m., Staff A stated QAPI program documentation for calendar years 2021 and 2022 showed no ongoing, patient centered QAPI program to improve the care, services, and operations of the agency.

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 for all patients and employees. Findings: Administrative records of ongoing patient centered QAPI program for the agency which showed data collection activities utilized in the agency's QAPI Program for calendar years 2021 and 2022 were requested. No data used for QAPI program activities was provided. On 02/16/23 at 4:00 p.m., Staff A stated documentation showed no program improvement data and no analysis of collected data that showed improved quality of patient care for calendar years 2021 and 2022.

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 patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations for all patients and employees. Findings: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of QAPI program activities to improve the care, services, and operations of the agency for calendar years 2021 and 2022 were requested. Documentation of governing body meeting minutes dated 01/04/21 and 01/02/22 included statement of: ‘QAPI program was reviewed’; and showed 12 month summary statements of SHP quality indicator data for calendar years 201 and 2022 was provided. Documentation showed no conduction of patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations. On 02/16/23 at 4:00 p.m., Staff A stated QAPI program documentation for calendar years 2021 and 2022 showed no ongoing QAPI program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations of the agency.

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 its infection control program surveillance monitoring and reporting was included in QAPI program activities for all patients and staff. Findings: Administrative records which showed documentation of the agency’s infection control program and its surveillance data was included in QAPI program activities for calendar years 2021 and 2022 was requested. No documentation was provided. . On 02/16/23 at 4:00 p.m., Staff A stated QAPI program activities for calendar years 2021 and 2022 did not include the agency’s infection control program and its surveillance data.

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 an OT evaluation was conducted for one (Patient #2) of 18 patients. Findings: Patient #2 A review of the POC dated 01/12/23 to 03/12/23 showed orders for OT to evaluate. A review of clinical documentation showed no OT evaluation was conducted. Documentation showed no patient/caregiver refusal of the OT evaluations, no physician notifications and no changes in orders. On 02/16/23 at 2:10 p.m., Staff B stated OT evaluations should have been conducted for patient #2.

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 a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: Administrative records of multi-disciplined skilled professional staff participation in the agency’s QAPI program for calendar years 2021 and 2022 was requested. No documentation which showed multi-disciplined skilled professional staff participation was provided. On 02/16/23 at 4:00 p.m., Staff A stated the agency had no QAPI program activities with multi-disciplined skilled professional staff participation in calendar years 2021 and 2022.

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 discharge summary was provided for two (Patients #15 and #16) of 18 patients. Findings: Patient #15 A review of the clinical record documented discharge from the agency on 01/06/23 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #16 A review of the clinical record documented discharge from the agency on 01/02/23 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. On 02/16/23 at 3:15 p.m., Staff B stated no discharge summaries for patients #15 and #16 were sent to the receiving service providers.