Every finding on record at Complete Home Health of Tishomingo LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/07/24 to 10/09/24. 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 in conjunction with a complaint (94496 and 103828) survey at the agency on 10/07/24 to 10/09/24. An entrance conference was conducted with Staff A. Staff A and B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the re-certification survey. No deficiencies were cited in relation to the complaint survey.

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: 1. physical therapy visit frequency was followed as ordered on the plan of care for two (Patient #6 and 7) of 13 patients; and 2. home health aide visit frequency was followed as ordered on the plan of care for one (Patient #7) of 13 patients. 1 Patient #6 A review of the plan of care dated 06/14/24 to 08/12/24 showed a physical therapy frequency of one visit per week for one week effective 06/14/24. A review of the clinical record showed no physical therapy visits were conducted the date of 06/14/24. A physician's order dated 07/05/24 showed the physical therapy visit was not performed due to "scheduling error". Patient #7 A review of the plan of care dated 06/29/24 to 08/27/24 showed a physical therapy order to treat and evaluate with a frequency ordered as two visits per week for four weeks, one visits per week for three weeks and two visits per week for one week. A review of the clinical record showed a physical therapy missed visit note dated 07/07/24 for the week of 07/14/24 to 07/20/24 (one of two visits completed) with a reason for the missed visit as "unable to reach", no documentation of patient or family refusal, no documented attempts for reschedule the visit and no change in the ordered frequency. 2. Patient #7 A review of the plan of care dated 06/29/24 to 08/27/24 showed a home health aide frequency of two visits per week for eight weeks and one visit per week for one week. A home health aide missed visits note dated 08/05/24 (one of two completed visits for the week of 08/04/24 to 08/10/24) documented the reason for the missed visits as staff already provided care, no documentation of patient or family refusal, no documented attempts to reschedule the visit and no change in the ordered frequency. On 10/09/24 at 12:50 pm., Staff B stated: 1.the ordered physical therapy frequency was not followed for Patients #6 and 7, and 2 the ordered home health frequency was no followed for Patient #7.

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 for two (Patient #2 and 5) of 13 patients. Patient #2 A review of the plan of care dated 06/27/24 to 08/05/24 showed a primary diagnosis of chronic obstructive pulmonary disease with no individualized interventions or goals developed for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 07/25/24 to 09/22/24 showed a primary diagnosis of Anemia with no individualized interventions or goals developed for the management of the primary diagnosis. On 10/09/24 at 12:20 pm, Staff B stated the plan of care should have been fully developed to include individualized interventions or goals for the primary diagnosis for Patient #2 and 5.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a home health aide supervisory visit was completed every 14 days for two (Patient #3 and 9) of 13 patients. Patient #3 A plan of care dated 08/04/24 to 10/02/24 documented a home health aide frequency of two visits per week for eight weeks. A review of the clinical record showed home health aide visits were completed on 08/11/24, 08/15/24, 08/21/24, 08/26/24 and 08/29/24 with supervisory visits completed on 08/13/24 and 08/29/24 (16 days between supervisory visits). Patient #9 A plan of care dated 08/04/24 to 10/02/24 documented a home health aide frequency of one visit per week for one week and two visits per week for eight weeks. A review of the clinical record showed home health aide visits were completed on 07/26/24, 07/29/24, 08/01/24 and 08/05/24 with supervisory visits completed on 07/23/24 and 08/07/24 (15 days between supervisory visits). On 10/09/24 at 12:45 pm, Staff B stated the home health aide supervisory visits were to be performed every 14 days and home health aide supervisory visits for Patients #3 and 9 exceeded 14 days.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 10/266/21-10/27/21. 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 10/26/21 through 10/26/21. 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 and clinical issues. Standard level deficiencies were cited as a result of the re-certification. GLOSSARY POC Plan of Care Pt Patient PT Physical Therapy

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 plan of care development included diagnosis appropriate interventions for one (Pt #15) of 17 patients. Pt #15 A review of the POC showed a certification period of 08/07/21 to 10/05/21 and documented a primary diagnosis of unspecified dementia. The plan of care documented the patient was oriented to self only with interventions to instruct the patient on self management of the disease process, to alert the physician of any physical complications, to instruct the patient on the importance of vaccines and to instruct the patient on the importance of advance care planning and advanced directives. On 10/27/21 at 1:13 pm., Staff A stated the plan of care did not provided patient specific interventions related to the primary diagnosis.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure PT supervisory visits were documented for two (Pts #5 and 6) of 17 patients. Pt 5 A review of the clinical record showed PT services ordered and completed during the certification period of 09/12/21-11/10/21 on the following dates: September 12, 17, 20, 27, 29, October 4, 6, 11, 13, 18 and 22. Documentations showed all visits completed by the PTA with the exception of 09/12/21 and 10/11/21. Documentation showed no PTA supervisory visits completed during the 43 days reviewed. Pt 6 A review of the clinical record showed PT visits ordered and completed during the certification period of 09/11/21-11/09/21 on the following dates: September 21, 22, 27 and 29. October 1, 5, 7, 12, 14 and 19. Documentation showed all visits completed by the PTA with the exception of 09/21/21 and 10/21/21. Documentation showed no PTA supervisory visits completed during the 46 days reviewed. On 10/26/21 at 1:15 pm, Staff A stated the PTA supervisory visits were to be completed every 30 days and the documentation did not show completion of PTA supervisory visits.