Every finding on record at Community Home Health, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/22/25 to 04/24/25. 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 04/22/25 to 04/24/25. An entrance conference was conducted with Staff A. Staff B was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff B, C and D. Deficiencies were cited as a result of the re-certification survey.

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 the physician was notified of missed skilled nurse visits for three (Patients #1, 2 and 9) of twenty-one patients. Patient #1 A review of the plan of care dated 01/28/25 to 03/28/25 showed a primary diagnosis of peritoneal abscess with a skilled nurse frequency of four visits per week for one week and three visits per week for six weeks. A review of the clinical record showed the following: Skilled nurse assessments dated 03/24/25 and 03/26/25 and a skilled nurse missed visit note (due to the patient and sister being able to change the incision dressing) dated 03/28/25 for the week of 03/24/25 to 03/28/25. Documentation showed two of three completed visits and no physician notification of the missed frequency. Patient #2 A review of the plan of care dated 01/12/25 to 03/12/25 showed a primary diagnosis of hypertensive heart with heart failure with a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A skilled nurse missed visit note (due to the patient having enough medications and can wait until next week) dated 02/19/25 for the week of 02/17/25 to 02/23/25. Documentation showed no completed visits for the week and no physician notification of the missed frequency. Patient #9 A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of encounter for change or removal of surgical wound dressing and a skilled nurse frequency of two visits per week for one week, three visits per week for three weeks. A physician's order dated 02/17/25 ordered continued skilled nurse frequency of three visits per week for three weeks. Skilled nurse assessments dated 01/27/25 and 01/29/25 and a skilled nurse missed visits (due to no answer at the door or phone) dated 01/31/25 for the week of 01/27/25 to 02/02/25 (two of three completed visits). Documentation showed no physician notification of the missed visit. Skilled nurse assessments dated 02/10/25 and 02/12/25 and a skilled nurse missed visits (due to an appointment with surgeon) dated 02/14/25 for the week of 02/10/25 to 02/16/25 (two of three completed visits). Documentation showed no physician notification of the missed visit. Skilled nurse assessments dated 02/17/25 and 02/20/25 and a skilled nurse missed visit (due to inclimate weather, the patient can manage) dated 02/19/25 for the week of 02/17/25 to 02/23/25 (two of three completed visits). Documentation showed no physician notification of the missed visit. On 04/23/25 at 1:30 pm., Staff B stated the physician was not notified of the missed skilled nurse visits for Patients #1, 2 and 9.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing services were provided as ordered for three (Patients #1, 2 and 9) of twenty-one patients. Patient #1 A review of the plan of care dated 01/28/25 to 03/28/25 showed a primary diagnosis of peritoneal abscess with a skilled nurse frequency of four visits per week for one week and three visits per week for six weeks. A review of the clinical record showed the following: Skilled nurse assessments dated 03/24/25 and 03/26/25 and a skilled nurse missed visit note (due to the patient and sister being able to change the incision dressing) dated 03/28/25 for the week of 03/24/25 to 03/28/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. Patient #2 A review of the plan of care dated 01/12/25 to 03/12/25 showed a primary diagnosis of hypertensive heart with heart failure with a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A skilled nurse missed visit (due to the patient having enough medications and can wait until next week) dated 02/19/25 for the week of 02/17/25 to 02/23/25 (no completed visits for the week.). Documentation showed no patient refusal, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. Patient #9 A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of encounter for change or removal of surgical wound dressing, a skilled nurse frequency of two visits per week for one week, three visits per week for three weeks, and a physician's order dated 02/17/25 for continued skilled nurse frequency of three visits per week for three weeks. Skilled nurse assessments dated 01/27/25 and 01/29/25 and a skilled nurse missed visits (due to no answer at the door or phone) dated 01/31/25 for the week of 01/27/25 to 02/02/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visits and no new orders to change the ordered frequency. Skilled nurse assessments dated 02/10/25 and 02/12/25 and a skilled nurse missed visits (due to an appointment with surgeon) dated 02/14/25 for the week of 02/10/25 to 02/16/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visits and no new orders to change the ordered frequency. Skilled nurse assessments dated 02/17/25 and 02/20/25 and a skilled nurse missed visit (due to inclimate weather, the patient can manage) dated 02/19/25 for the week of 02/17/25 to 02/23/25 (two of three completed visits). Documentation showed no patient refusal, no attempts to reschedule the missed visit and no new orders to change the ordered frequency. On 04/23/25 at 1:30 pm., Staff B stated the skilled nurse frequencies were not met for Patients #1, 2 and 9.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/21/22 to 06/23/22. 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 06/21/22 to 06/23/22.An entrance conference was conducted with Admin1 and Director1. The survey process was explained. Questions were answered.Admin1 was identified as the contact person for administrative issues and Director1 as the contact person for clinical issues.Findings were discussed during an informal exit conference with Admin1, Director1 and Administrative staff members.Standard level deficiencies were cited as a result of the re-certification survey.GLOSSARY: Admin Administrator SN Skilled Nurse POC Home Health Certification and Plan of Care SOC Start of Care QAPI Quality Assurance Performance Improvement PIP Performance Improvement Project

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN staff identified all medications currently taken by the patients and failed to conduct a review of all medications to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for three ( #7, #8 and #14) of seventeen (#1 - #17) records reviewed. Patient #7 A review of the record for Patient #7 with a SOC date of 05/23/22 and initial period 05/23/22 to 07/21/22 with a Primary Diagnosis of Multiple Fractured Ribs failed to provided evidence the SN conducted a review of all medications as part of the comprehensive assessment at the SOC. Patient # 8 A review of the POC for Patient #8 for the period 06/07/22 to 08/05/22 revealed a Primary Diagnosis of Malignant Neoplasm of Lung. Documentation by the SN at SOC revealed the patient reported "getting CHEMO every 3 weeks". Further review of a document titled "Medication Profile" failed to provide evidence of the chemotherapy medications Patient #8 was currently receiving. Patient # 14 A review of the record for Patent #14 with a SOC date of 01/26/22 and recertification period 03/27/22 to 05/25/22 revealed a Primary Diagnosis of Aftercare following Joint Replacement Surgery. Further record review failed to provide evidence the SN conducted a review of all medications as part of the comprehensive assessment for the recertification period. During an interview on 06/23/22 at 1:15 pm, Director1 stated the SN staff did not include the chemotherapy medications on the medication list for Patient #8 and did not conduct a review of all medications as required for Patients #7, #8 and #14.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure SN staff assessed the patient's blood glucose and/or weight to ensure timely reporting of changes to the physician as ordered for three (#1, #10 and #12) of eight (#1,#2,#5,#6, #9,#10,#12 and #15) records with orders to report blood glucose or weight results outside parameters to the physician. Patient #1 A review of the POC for Patient #1 for the period 06/01/22 to 07/30/22 with a Primary Diagnosis of Chronic Obstructive Pulmonary Disease with a secondary diagnosis of Type 2 Diabetes Mellitus included orders to "Notify physician of: Fasting Blood Sugar greater than 240 or less than 70 and Random Blood Sugar greater than 240 and less than 70". During an interview on 06/22/22 at 10:00 am, the Caregiver for Patient #1 stated, " The nurses check his blood sugar when they visit". Further review of SN visit notes revealed the SN failed to obtain blood sugar results for SN visits conducted 06/01/22, 06/03/22 and 06/07/22. Patient #10 A review of the POC for Patient #10 for the period 05/24/22 to 07/22/22 with a Primary Diagnosis of Stenosis of Cardiac Prosthetic Device/Graft with a secondary diagnosis of Type 2 Diabetes Mellitus with Chronic Kidney Disease included orders to "Notify physician of: Fasting Blood Sugar greater than 240 or less than 70 and Random Blood Sugar greater than 240 and less than 70" and to "Report any weight gain of 3-5 pounds over 2-3 days". Further review of SN visit notes revealed the SN failed to obtain the patient's weight for the SN visit conducted 06/09/22 and failed to obtain both weight and blood sugar results for the SN visit conducted 06/14/22. Patient #12 A review of the POC for Patient #12 for the period 05/16/22 to 07/14/22 with a Primary Diagnosis of Unspecified Fracture of Sacrum with a secondary diagnosis of Type 2 Diabetes Mellitus included orders to "Notify physician of: Fasting Blood Sugar greater than 240 or less than 70 and Random Blood Sugar greater than 240 and less than 70." Further review of SN visit notes revealed the SN failed to obtain blood sugar results for the SN visits conducted 05/24/22, 05/31/22 and 06/09/22. During an interview on 06/23/22 at 1:15 pm, Director1 stated the SN staff did not obtain the blood sugar results and weights for Patients #1, #10 and #12.

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 interviews, the Agency failed to conduct a Performance Improvement Project based on QAPI program activities and data as required. A review of QAPI Meeting minutes revealed the agency identified a Performance Improvement Project (PIP) in 2018 to address Urinary Tract Infections and the Governing Board approved the PIP to begin 2019. Further review of QAPI meeting minutes and Governing Board minutes for the years 2019, 2020, 2021 and current 2022 failed to provide evidence of documentation regarding the PIP implementation, measurable progress or current status. During an interview on 06/23/22 at 1:15 pm, Admin2 stated there was no documentation of the PIP.