Every finding on record at Duncan Regional Hospital Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program Survey at the agency on 10/21/24 - 10/22/24. No Deficiencies were cited as a result of the Emergency Preparedness Survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/21/24 - 10/22/24. An entrance conference was conducted with Staff A, B, C and D. 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, B, C, D and E. Deficiencies were cited as a result of the re-certification survey.

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 an individualized patient POC was completed for one (Patient #5) of seven patients. Findings: Patient #5 A review of the clinical record showed no POC for episode dated 09/25/24 to 11/23/24. On 10/21/24 at 2:33 PM, Staff A stated a POC was developed and under review but was not available when the record was reviewed.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Patient #1) of two patients with home health aide services. Findings: Patient #1 A plan of care dated 08/20/24 to 10/18/24 ordered home health aide visits once a week for one week and then twice a week for seven weeks. A review of the clinical record showed CHHA visits completed 09/20/24, 09/24/24, 09/26/24, 10/01/124, and 10/03/19 with CHHA supervisory visits 9/18/24, 10/03/24 (15 days with no CHHA supervisory visits completed). On 10/22/24 2:30 PM, Staff B stated the supervisory visits from 9/18/24 to 10/03/24 for patient #1 were not completed within 14 days.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 12/01/21 to 12/02/21. 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 12/01/21 to 12/02/21. 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, B, C and D. A deficiency was cited as a result of the re-certification survey:

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 three (Patient #1, 3 and 7) of thirteen patients. Patient #1 A review of the plan of care dated 09/11/21 to 11/09/21 showed a primary diagnosis of urinary tract infection. The plan of care showed no interventions related specifically to the primary diagnosis and no goals related specifically to the primary diagnosis. Patient #3 A review of the plan of care dated 09/02/21 to 11/03/21 showed a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure. The plan of care failed to document weight parameters for physician notification, interventions regarding weight measurement and teaching the patient the importance of monitoring weight in relation to the primary diagnosis. Patient #7 A review of the plan of care dated 08/30/21 to 10/28/21 showed a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure. The plan of care failed to document weight parameters for physician notification, interventions regarding weight measurement and teaching the patient the importance of monitoring weight in relation to the primary diagnosis. On 12/02/21 at 1:10 pm., Staff B stated the plan of care should have documented interventions and goals related to the primary diagnosis for Patient #1 and the plan of care should have documented weight measurement and weight parameters to notify the physician in relation to the primary diagnosis for Patients #3 and 7.