Every finding on record at Country Style Health Care, Inc XII

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/12/24 to 03/14/24. 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 03/12/24 to 03/14/24. 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 clinical and administrative 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. Glossary: POC Plan of Care SN Skilled Nurse/Nursing PT Physical Therapy

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN frequencies were followed as ordered for two (Patients #3 and 6) of seven patients; 2. SN notified the physician of a diastolic blood pressure and a pain level outside the ordered parameters for one (Patient #6) of seven patients; and 3. PT frequencies were followed as ordered for two (Patient #6 and 7) of seven patients. 1. Patient #3 A review of the POC dated 12/29/23 to 02/26/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 01/05/24 which documented the reason as patient was not scheduled, and no other visits for the week of 12/31/23 to 01/06/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #6 A review of the POC dated 12/20/23 to 02/17/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 02/09/24 which documented the reason as no answer to phone call, and no other visits for the week of 02/04/24 to 02/10/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 2. Patient #6 A review of the POC dated 12/20/23 to 02/17/24 showed an order for the physician to be notified of diastolic blood pressure less than 60 and of pain level greater than five out of ten. A review of a SN visit dated 01/03/24 showed a diastolic reading of 54 and a reported pain level of nine out of ten. Documents showed no physician notification for the diastolic blood pressure reading less than 60 and for the reported pain greater than five. 3. Patient # 6 A review of the POC dated 12/20/23 to 02/17/24 showed an order for PT to evaluate and treat. A review of a PT evaluation dated 12/29/23 showed a frequency of one visit per week for one week (effective 12/29/23) and two visits per week for three weeks (effective 12/31/23). A review of the medical records showed: A PT missed visit dated 01/09/24 which documented the reason as no answer to locked door and a PT missed visit dated 01/12/24 which documented the reason as caregiver able to assist patient, and no other visits made for the week of 01/07/24 to 01/13/24 (two of two ordered visits not completed). A PT missed visit dated 01/16/24 which documented the reason as no answer to phone call and a PT missed visit dated 01/19/24 which documented the reason as no answer to locked door, and no other visits made for the week of 01/14/24 to 01/20/24 (two of two ordered visits not completed). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #7 A review of the POC dated 01/05/24 to 03/04/24 showed an order for PT to evaluate and treat. A review of a PT evaluation dated 01/08/24 showed a frequency of two visits per week for five weeks. A review of the medical records showed no PT visits were made for the week of 02/04/24 to 02/10/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. On 03/14/24 at 9:47 a.m., Staff A stated: 1. the SN frequencies for Patients #3 and 6 were not met as ordered by the physician; 2. there was no documentation of physician notification of the diastolic blood pressure and the pain level being out of parameters for Patient #6; and 3. the PT frequencies for Patients #6 and 7 were not met as ordered by the physician.