Every finding on record at Compassion Home Care, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/10/24. 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 on12/10/24. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff B and C were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, and D. Standard level deficiencies were cited as a result of the Medicare re-certification survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an individualized plan of care was developed for seven (Patients #1, 3, 4, 5, 6, 7 and 8) of 14 patients. Patient #1 A review of the plan of care dated 11/23/24 to 01/21/25 showed a primary diagnosis of hypertensive chronic kidney disease with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 11/12/24 to 01/10/25 showed a primary diagnosis of chronic venous hypertension with ulcer to lower extremities with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 10/15/24 to 12/13/24 showed a primary diagnosis of multiple sclerosis with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 11/21/24 to 01/19/25 showed a primary diagnosis of hypertensive heart disease with heart failure with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 11/11/24 to 01/09/25 showed a primary diagnosis of hypertensive heart chronic kidney disease with heart failure with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. Patient #8 A review of the plan of care dated 11/18/24 to 01/16/25 showed a primary diagnosis of atrial fibrillation with no patient specific individualized interventions or goals developed for the management of the primary diagnosis. On 12/10/24 at 2:14 pm, Staff C stated the plan of care for Patients #3, 4, 6, 7 and 8 were not individualized for the management of the primary diagnosis. On 12/10/24 at 2:25 pm, Staff A stated the plan of care for Patients #1 and 5 were not individualized for the management of the primary diagnosis.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: 1. promptly notify the physician of a significant weight loss for one (Patient #4) of 14 patients; 2. promptly notify the physician of weights outside of ordered parameters for one (Patient #4) of 14 patients; and 3. promptly notify the physician of pain levels outside of ordered parameters for one (Patient #4) of patients. Patient #4 1. A review of the plan of care dated 10/15/24 to 12/13/24 showed a primary diagnosis of multiple sclerosis and documented a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A skilled nurse assessment dated 11/27/24 documented the patient weight of 123 pounds. A skilled nurse assessment dated 12/05/24 documented the patient's weight of 110 pounds (a 13-pound weight loss within an 8-day period), with no physician notification of the significant weight loss. 2. A review of the plan of care dated 10/15/24 to 12/13/24 showed the physician was to be notified of weights less than 105 pounds and greater than 115 pounds. A skilled nurse assessment dated 10/17/24 documented a weight of 122 pounds (7 pounds greater than the high parameter) and documented the physician was not notified until 10/18/24 (one day after the assessment). A skilled nurse assessment dated 10/24/24 documented a weight of 122 pounds (7 pounds greater than the high parameter) and documented the physician was not notified until 10/25/24 (one day after the assessment). A skilled nurse assessment dated 10/31/24 documented a weight of 123 pounds (8 pounds greater than the high parameter) and documented the physician was not notified until 11/01/24 (one day after the assessment). A skilled nurse assessment dated 11/07/24 documented a weight of 124 pounds (9 pounds greater than the high parameter) and documented the physician was not notified until 11/08/24 (one day after the assessment). A skilled nurse assessment dated 11/14/24 documented a weight of 123 pounds (8 pounds greater than the high parameter) and documented the physician was not notified until 11/15/24 (one day after the assessment). A skilled nurse assessment dated 11/21/24 documented a weight of 124 pounds (9 pounds greater than the high parameter) and documented the physician was not notified until 11/22/24 (one day after the assessment). A skilled nurse assessment dated 11/27/24 documented a weight of 123 pounds (8 pounds greater than the high parameter) and documented the physician was not notified until 11/29/24 (two days after the assessment). 3. A review of the plan of care dated 10/15/24 to 12/13/24 showed the physician was to be notified of a pain level greater than a 7 of 10 on the classic 1-10 pain scale. A skilled nurse assessment dated 10/17/24 documented a pain level of 8 and documented the physician was not notified until 10/18/24 (one day after the assessment). A skilled nurse assessment dated 10/24/24 documented a pain level of 8 and documented the physician was not notified until 10/25/24 (one day after the assessment). A skilled nurse assessment dated 10/31/24 documented a pain level of 8 and documented the physician was not notified until 11/01/24 (one day after the assessment). A skilled nurse assessment dated 11/07/24 documented a pain level of 8 and documented the physician was not notified until 11/08/24 (one day after the assessment). A skilled nurse assessment dated 11/21/24 documented a pain level of 8 and documented the physician was not notified until 11/22/24 (one day after the assessment). On 12/10/24 at 2:30 pm., Staff C stated: 1. the physician was not notified of the 13-pound weight loss for Patient #4 and should have been notified of the significant weight loss; 2. the physician was not notified the day of the weights for Patient #4 exceeding the ordered parameters; and 3. the physician was not notified the day of the pain levels exceeding the ordered parameters for Patient #4.