Every finding on record at Country Style Healthcare, Inc. XI

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 03/11/24 to 03/12/24. 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 03/11/24 to 03/12/24. 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 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.

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 the physician was notified of a weight gain outside of ordered parameters for one (Patient #7) of seven patients. Patient #7 A review of the plan of care dated 11/29/23 to 01/27/24 showed a primary diagnosis of hypertensive heart with heart failure and documented the patient was to report to the nurse a weight gain of three pounds in one day or five in one week and the skilled nurse was to assess the patient's weight log every visit. A review of the clinical record showed the following: An initial skilled nurse assessment dated 11/29/23 documented a weight of 186 pounds for the week of 11/29/23 to 12/02/23. A skilled nurse assessment dated 12/06/23 documented a weight of 200 pounds (a weight gain of 14 pounds in one week) for the week of 12/03/23 to 12/19/23. No notification of the weight gain was made to the physician and no interventions were documented. On 03/12/24 at 2:10 pm., Staff A stated the physician was not notified of the 14 pound weight increase and no interventions were documented.

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 hospice failed to ensure the plan of care was fully developed to include individualized interventions in relation to the primary diagnosis for one (Patients #4) of 7 patients reviewed. Patient #4 A review of the plan of care dated 01/11/24 to 03/12/24 showed a primary diagnosis of chronic pain and showed no patient specific interventions for the management of the primary diagnosis. On 03/12/24 at 2:30 pm, Staff A stated there were no patient specific interventions for the primary diagnosis for Patient #4.

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 a significant change in weight for one (Patient #7) of seven patients. Patient #7 A review of the plan of care dated 11/29/23 to 01/27/24 showed a primary diagnosis of hypertensive heart with heart failure and documented the patient was to report to the nurse a weight gain of three pounds in one day or five in one week and the skilled nurse was to assess the patient's weight log every visit. A review of the clinical record showed the following: An initial skilled nurse assessment dated 11/29/23 documented a weight of 186 pounds for the week of 11/29/23 to 12/02/23. A skilled nurse assessment dated 12/06/23 documented a weight of 200 pounds (a weight gain of 14 pounds in one week) for the week of 12/03/23 to 12/19/23. No notification of the weight gain was made to the physician and no interventions were documented. On 03/12/24 at 2:10 pm., Staff A stated the physician should have been notified of the 14-pound weight increase.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a repeated elevation in pain was coordinated with the physician for one (Patient #5) of seven patients. Patient #5 A review of the plan of care dated 12/21/23 to 02/18/24 showed a skilled nurse frequency of one visit per week for eight weeks and documented to notify the physician of a pain level greater than 5 on the classic 1-10 pain scale. A review of the clinical record showed the following: A skilled nurse assessment dated 12/27/23 documented a pain level of 7 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. A skilled nurse assessment dated 01/05/24 documented a pain level of 7 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. A skilled nurse assessment dated 01/11/24 documented a pain level of 7 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. A skilled nurse assessment dated 01/19/24 documented a pain level of 7 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. A skilled nurse assessment dated 01/27/24 documented a pain level of 6 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. A skilled nurse assessment dated 02/02/24 documented a pain level of 6 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. A skilled nurse assessment dated 02/09/24 documented a pain level of 7 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. A skilled nurse assessment dated 02/16/24 documented a pain level of 7 on the classic 1-10 pain scale. A fax was sent to the physician with no documented follow up to the fax. Eight of eight faxes were sent with no documented follow up to the patients elevated pain. On 03/12/24 at 2:15 pm., Staff A stated there was no documented follow up to the faxes to the physician regarding the elevated pain levels for Patient #5.