Every finding on record at Country Style Health Care VIII

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/06/23 to 02/07/23. 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 02/06/23 to 02/07/23. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as an alternate contact person for administrative and clinical issues, Staff C was identified as the contact person for clinical issues and Staff D was identified as the contact person for administrative issues. Findings were discussed during an informal exit conference with Staff C and D. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary notices BP blood pressure BS blood sugar HHCOC Home Health Change of Care Notice PT Physical therapy 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 advance beneficiary notice and/or HHCOC notice was provided to one (Patient #7) of seven patients. Findings: Patient #7 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 11/16/22 for insurance payer denial of payment for services. On 02/07/23 at 10:15 a.m., Staff D stated there was no ABN or HHCOC notices in the clinical record and patient #7 should have received ABN and/or HHCOC notices prior to being discharged from the agency for insurance payer denial of payment for 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 pain reporting parameters for four (Patients #1, 2, 4 and #5) of seven patients. Findings: Patient #1 A review of a POC dated 01/05/23 to 03/05/23 showed orders for a SN visit frequency of one time a week for eight weeks and SN to assess, instruct, monitor and report to the physician the patient’s pain level. A review of clinical documentation showed no physician pain reporting parameters on the POC. Documentation showed patient reported pain levels during SN visits dated 01/13/23 of 5 of 10; 01/20/23 reported pain level of 5 of 10, 01/24/23 reported pain level of 5 of 10 and on 02/06/23 reported pain level of 5 of 10. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/07/23 at 9:45 a.m., Staff D stated the POC for patient #1 should have included physician pain reporting parameters. Patient #2 A review of a POC dated 12/31/22 to 02/28/23, showed orders for a SN visit frequency of one time a week for nine weeks and for SN to assess, instruct, monitor and report to the physician the patient’s pain level. A review of clinical documentation showed no physician pain reporting parameters on the POC. Documentation showed patient reported pain levels during SN visits dated 01/06/23 of 8 of 10; 01/12/23 reported pain level of 6 of 10; 01/19/23 reported pain level of 3 of 10 and on 01/30/23 reported pain level of 9 of 10. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/07/23 at 9:47 a.m., Staff D stated the POC for patient #2 should have included physician pain reporting parameters. Patient #4 A review of a POC dated 01/03/23 to 03/03/23, showed orders for a SN visit frequency of one time a week for eight weeks and for SN to assess, instruct, monitor and report to the physician the patient’s pain level. A review of clinical documentation showed no physician pain reporting parameters on the POC. Documentation showed patient reported pain levels during SN visits dated 01/04/23 of 5 of 10; 01/06/23 reported pain level of 5 of 10; 01/09/23 reported pain level of 5 of 10; 01/11/23 reported pain level of 5 of 10 and on 01/13/23 reported pain level of 5 of 10. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/07/23 at 9:50 a.m., Staff D stated the POC for patient #4 should have included physician pain reporting parameters. Patient #5 A review of a POC dated 01/13/23 to 03/13/23, showed orders for a SN visit frequency of one time a week for nine weeks and for SN to assess, instruct, monitor and report to the physician the patient’s pain level. A review of clinical documentation showed no physician pain reporting parameters on the POC. Documentation showed patient reported pain levels during SN visits dated 01/16/23 of 2 of 10 and on 02/02/23 reported pain level of 2 of 10. Documentation showed no physician notification of the patient’s reported pain levels and no change in orders. On 02/07/23 at 9:55 a.m., Staff D stated the POC for patient #5 should have included physician pain reporting parameters.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for two (Patient #2 and #3) of seven patients. Findings: Patient #2 A review of a plan of care dated 12/31/22 to 02/28/23 documented a primary diagnosis of hypertension and Diabetes Mellitus Type II and showed a physician reporting parameter of Blood pressure 150/90 and a blood sugar level greater than 250. A SN visit note dated 01/06/23 showed a BP of 178/90 and BS of 315 and the vital sign alert was auto-faxed to the physician with no follow up. A SN visit note dated 01/19/23 showed a BP of 180/94 and the vital sign alert was auto-faxed to the physician with no follow up. A SN visit note dated 01/30/23 showed a BP of 190/118 (with a pulse rate of 112) and the vital sign alert was auto-faxed to the physician with no follow up. Documentation showed no direct physician coordination of care communications as follow up to the changes in the patient’s BP and BS status and no changes in orders. On 02/07/23 at 9:47 a.m., Staff D stated the vital sign alerts for patient #2 that were auto-faxed by the computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in BP and BS status. Patient #3 A review of a plan of care dated 01/01/23 to 03/01/23 documented a primary diagnosis of Diabetes Mellitus Type II and showed a physician reporting parameter of blood sugar level greater than 250. A SN visit note dated 01/18/23 showed a BS of 283 and the vital sign alert was auto-faxed to the physician with no follow up. Documentation showed no direct physician coordination of care communications as follow up to the changes in the patient’s BP and BS status and no changes in orders. On 02/07/23 at 9:49 a.m., Staff D stated the vital sign alert for patient #3 that was auto-faxed by the computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in BS status.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the POC for: SN to assess, monitor and notify physician for patient weight levels outside of reporting parameters for three (Patient #1, 5 and #6) of seven patients; SN to conduct Huber needle site maintenance care and line flush every month one (Patient #1) of seven patients and; PT visit frequency for one (Patients #2) of seven patients. Patient #1 A review of the POC dated 01/05/23 to 3/05/23 showed orders for SN to assess, monitor and report patient weight outside of reporting parameters every visit and SN to perform Huber needle site maintenance care with needle flush every month due week of 01/15/23. SN visit notes dated 01/13/23, 01/20/23, 01/24/23 and 02/04/23 showed no patient weight was obtained and no Huber needle site maintenance care with needle flush was conducted during the SN visits. Documentation showed no patient/caregiver refusal of weight monitoring, no refusal of Huber needle site maintenance care, no physician notifications and no changes in orders. On 02/07/23 at 9:45 p.m., Staff D stated the SN visit notes did not show patient weight monitoring or Huber needle site maintenance care had been conducted as ordered on the POC as ordered for patient #1. Patient #2 A review of the POC dated 12/31/22 to 02/28/23 showed orders for PT visit frequency of two times a week for four weeks. A review of visit notes showed during weeks of 01/15/23 to 01/21/23 one PT visit was conducted (one visit not conducted) and during week of 01/22/23 to 01/28/23 one PT visit was conducted (one visit not conducted). Documentation showed no patient/caregiver refusal of the PT visits, no physician notifications and no changes in orders. On 02/07/23 at 9:47 a.m., Staff D stated patient #2 did not have a PT visits conducted as ordered. Patient #5 A review of the POC dated 01/13/23 to 3/13/23 showed orders for SN to assess, monitor and report patient weight outside of reporting parameters every visit A review of SN visits dated 01/16/23 and on 02/02/23 showed no patient weight was obtained during the SN visits. Documentation showed no patient/caregiver refusal of weight monitoring, no physician notifications and no changes in orders. On 02/07/23 at 9:55 a.m., Staff D stated the SN visit notes did not show patient weight monitoring had been conducted as ordered on the POC as ordered for patient #5. Patient #6 A review of the POC dated 11/09/22 to 01/07/23 showed orders for SN to assess, monitor and report patient weight outside of reporting parameters every visit. SN visits dated 11/11/22, 11/14/22, 11/16/22, 11/30/22, 12/02/22, 12/08/22, 12/13/22 and12/21/22 showed no patient weight was obtained during the SN visits. Documentation showed no patient/caregiver refusal of weight monitoring, no physician notifications and no changes in orders. On 02/07/23 at 10:05 a.m., Staff D stated the SN visit notes did not show patient weight monitoring had been conducted as ordered on the POC as ordered for patient #6.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided for two (Patients #4 and #6) of seven patients. Findings: Patient #4 A review of the clinical record documented transfer from the agency on 01/16/23 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. Patient #6 A review of the clinical record documented transfer from the agency on 12/25/22 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. On 02/07/23 at 10:05 a.m., Staff D stated no transfer summaries were sent to the receiving service providers for patient #4 and #6.