Every finding on record at Completecare Home Health, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/11/24 to 06/12/24. 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 on 06/11/24 to 06/12/24. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff A and C. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary notice POC plan of care SN skilled nurse

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 an ABN was provided prior to being discharged from the agency for one (Patient #7) of 10 patients. Findings: Patient #7 A review of the clinical record showed the patient was discharged from the agency on 12/28/23 for a change in payor source effective 01/01/24 and showed no documentation of an advance notice of discharge prior to discharge from the agency. On 06/12/24 at 9:25 a.m., Staff A stated Patient #7 received no advance notice of discharge prior to their discharge from agency services.

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 individualized patient POC included an identified wound site location for one (Patient #3) of 10 patients. Findings: Patient #3 A review of the POC dated 05/11/24 to 07/09/24 showed orders for SN to conduct wound site assessment and treatment interventions every visit but did not identify the wound site location on the POC. Documentation showed no physician notifications and no change in orders until an interim (verbal) physician’s order dated 05/15/24 was received (4 days from the start of the POC). On 06/12/24 at 11:32 a.m., Staff A stated the POC for patient #3 did not identify the wound site location to receive wound site treatment interventions until an interim (verbal) physician’s order was received on 05/15/24.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 07/20/21 to 07/21/21. 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 07/20/21 - 07/21/21. An entrance conference was conducted with Staff A and B. 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 and B. Standard level deficiencies were sited as a result of the survey. Glossary: Pt Patient Pts Patients

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 the initial assessment was performed within 48 hours of the referral for two (Pt #4 and 7) of seven patients. Findings: Pt #4 A review of the clinical record showed a patient referral dated 01/31/20. A review of clinical documentation showed an initial patient assessment and SOC dated 02/03/20 (three days later). Documentation showed no physician request to delay the initial assessment and no patient or caregiver refusal of visits. Pt #7 A review of the clinical record showed a patient referral dated 07/10/20. A review of clinical documentation showed an initial patient assessment and SOC dated 07/13/20 (three days later). Documentation showed no physician request to delay the initial assessment and no patient or caregiver refusal of visits. On 07/21/21 at 11:43 am, Staff B stated he was unable to provide documentation or reason the initial assessment was not completed within 48 hours of the referral for Pts #4 and 7.