Every finding on record at Country Style Health Care, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 11/16/21 to 11/17/21. 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 11/16/21 to 11/17/21. 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 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. Deficiencies were cited as a result of the re-certification survey.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the resolution of two of two complaints. Complaint #1 A review of agency records showed a complaint dated 11/24/21 which documented no resolution or follow-up. Complaint #2 A review of agency records showed a complaint dated 05/25/21 which documented no resolution or follow-up. On 11/16/21 at 1:25 pm., Staff A stated no resolution or follow-up documented for Complaint #1and 2.

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 development of an individualized plan of care for one (Patient #1) of seven patients. A review of the plan of care dated 09/04/21 to 11/02/21 showed a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure and with stage 5 end stage renal disease and documented a skilled nurse frequency of one visit per week for nine weeks. The plan of care documented the skilled nurse was to assess the patient's weight log every visit and weigh the patient every visit if the patient was able. The plan of care failed to document teaching the patient the importance of monitoring weight in relation to the primary diagnosis. A review of the clinical record showed the following: A skilled nurse assessment dated 09/09/21 documented the patient declined to weigh. A skilled nurse assessment dated 09/14/21 documented the patient declined to weigh. A skilled nurse assessment dated 09/23/21 documented the patient declined to weigh. A skilled nurse assessment dated 09/30/21 documented the patient declined to weigh. A skilled nurse assessment dated 10/05/21 documented the patient declined to weigh. A skilled nurse assessment dated 10/14/21 documented the patient declined to weigh. A skilled nurse assessment dated 10/19/21 documented the patient declined to weigh. A skilled nurse assessment dated 10/26/21 documented the patient declined to weigh. On 11/17/21 at 10:20 am., Staff B stated the plan of care should have documented teaching the patient the importance of obtaining weights in relation to 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 ensure the physician was notified of the use of a nebulizer for one (Patient #6) of seven patients. Patient #6 A review of the plan of care dated 03/09/21 to 05/07/21 showed a primary diagnosis of asthma and documented no use of a nebulizer machine or nebulizer medications. A skilled nurse assessment dated 03/18/21 documented the patient reported using her daughter's nebulizer machine to breath well "especially at night", with no documentation of physician notification of the use of the nebulizer or the patient stating the use of the machine to improve breathing. On 11/17/21 at 10:25 pm., Staff B stated the physician should have notified the physician of the use of daughter's nebulizer machine for Patient #6.