Every finding on record at Gentle Shepherd Home Health, Incorporated

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/02/24 to 01/04/24. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of emergency preparedness records showed no administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency were in place. On 01/04/24 at 1:30 p.m., Staff B stated the agency did not have an Emergency Preparedness Plan with administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff. Findings: A review of emergency preparedness records showed no updated Emergency Preparedness Communication Plan which included current staff contact information for the agency. On 01/04/24 at 1:30 p.m., Staff B stated the Emergency Preparedness Communication Plan was not updated to include contact information for current staff of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with complaint investigations for complaint #70728 and #94887 at the agency on 01/02/24 to 01/04/24. 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 issues and Staff B and C were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff B and C. Standard level deficiencies related to complaint allegations were cited as a result of the survey. Glossary: ALF Assisted Living Facility BS blood sugar CHHA certified home health aide HHA Home Health Agency OT Occupational Therapy PIP performance improvement project POC Plan of Care SN skilled nurse

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to: 1. Educate the patient on potential health outcomes related to refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance and; 2. Notify the physician of the patient's continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance for one (Patient #11) of 12 patients. Findings: Patient #11 A review of a POC for 09/03/23 to 11/01/23 showed a SN visit frequency of one time a week for nine weeks. A review of visit notes showed missed SN visits on 10/06/23, 10/12/23, 10/18/23 and on 10/25/23. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of and/or missed SN visits and no documentation to the physician of the patient's continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance. On 01/04/24 at 2:45 p.m., Staff B stated documentation showed no: 1. Attempts to educate the patient of potential health outcomes related to refusal of and/or missed SN visits and; 2. No physician notification of the patient's continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance.

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 documentation of investigation and resolution of a complaint with a patient’s representative/family member for one (Patient #15) of 12 patients. Findings: Patient #15 A review of administrative records showed no documentation of the patient’s representative/family member complaint related to the 05/29/23 SN medication error incident. Administrative records showed documentation of the medication error incident on 05/29/23 (SN was ordered to administer Lantus 10 units subcutaneously and administered Lantus 30 units subcutaneously). Documentation showed no notification to the complainant of the investigation and resolution of the complaint related to the medication error incident by agency SN staff. On 01/03/24 at 3:02 p.m., the complainant (anonymous, name withheld) stated on 05/29/23 the agency nurse administered three times the insulin dose that was ordered. The complainant stated the SN called to notify her of the medication error and she (complainant) had to spend the day and night at the ALF to monitor the patient’s blood sugar levels because the agency would not. The complainant further stated she called the agency to lodge a complaint and was told the agency was looking into it and would educate the staff as needed. The complainant stated the agency made no contact related to investigation and resolution of the complaint. On 01/04/24 at 1:30 p.m., Staff B stated the agency had no documentation which showed contact with the complainant related to investigation and resolution of the complaint from the 05/29/23 medication error incident.

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 POCs included: 1. Pain reporting parameters for physician notification and related SN goals for five (Patients #2, 4, 6, 10 and 11) of 12 patients and; 2. Identified wound site for SN wound site management and interventions for one (Patients #3) of 12 patients. Findings: Patient #2 A review of the POC dated 11/26/23 to 01/24/24 showed orders for SN to assess, monitor and instruct patient’s pain level every visit. POC documentation showed no pain reporting parameters for physician notification and no related SN goals. SN visits conducted on 11/27/23 showed a patient reported pain level of 3. Additional SN visits (daily) from 11/28/23 to 01/02/24 showed no patient reported pain levels. Documentation showed no physician notifications and no change in orders. On 01/04/24 at 1:50 p.m., Staff B stated the POC for patient #2 had no physician pain reporting parameters. Patient #3 A review of the POC dated 12/01/23 to 01/29/24 showed orders for SN to perform wound site care management with interventions. POC showed documentation of wound site care for two identified sites (left heel and left buttock) and one unidentified site (identified in other documentation as the sacrum). Documentation showed no physician notifications to identify the third wound site and showed no change in orders. On 01/04/24 at 2:00 p.m., Staff B stated the POC for patient #3 showed wound site interventions for three wound sites but only identified a wound site to the left heel and the left buttock. Patient #4 A review of the POC dated 11/11/23 to 01/09/24 showed orders for SN to assess, monitor and instruct patient’s pain level every visit. POC documentation showed no pain reporting parameters for physician notification and no related SN goals. SN visits conducted (daily) from 11/11/23 to 01/02/24 showed no patient reported pain levels. Documentation showed no physician notifications and no change in orders. On 01/04/24 at 1:50 p.m., Staff B stated the POC for patient #4 had no physician pain reporting parameters. Patient #6 A review of the POC dated 11/12/23 to 01/10/24 showed orders for SN to assess, monitor and instruct patient’s pain level every visit. POC documentation showed no pain reporting parameters for physician notification. SN visits conducted on 11/20/23 reported pain level of 3, 11/27/23 reported pain level of 3, 11/29/23 reported pain level of 3, 12/01/23 reported pain level of 2, 12/04/23 reported pain level of 3, 12/06/23 reported pain level of 2, 12/08/23 reported pain level of 3 and on 12/20/23 reported pain level of 1. Documentation showed no physician notifications and no change in orders. On 01/04/24 at 2:30 p.m., Staff B stated the POC for patient #6 had no physician pain reporting parameters. Patient #10 A review of the POC dated 11/30/23 to 01/28/24 showed orders for SN to assess, monitor and instruct patient’s pain level every visit. POC documentation showed no pain reporting parameters for physician notification and no related SN goals. SN visits conducted on 11/30/23 showed no reported pain level. Documentation showed no physician notifications and no change in orders. On 01/04/24 at 2:42 p.m., Staff B stated the POC for patient #10 had no physician pain reporting parameters. Patient #11 A review of the POC dated 09/03/23 to 11/01/23 showed orders for SN to assess, monitor and instruct patient’s pain level every visit. POC documentation showed no pain reporting parameters for physician notification. SN visits conducted on 09/06/23 reported pain level of 3, 09/13/23 reported pain level of 3 and on 09/19/23 reported pain level of 3. Documentation showed no physician notifications and no change in orders. On 01/04/24 at 2:45 p.m., Staff B stated the POC for patient #11 had no physician pain reporting parameters.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were a part of the patients’ plans of care for: 1. SN to provide monthly catheter changes and indwelling urinary catheter management for one (Patient #3) of 12 patients; 2. SN to administer daily medications and perform SN interventions to change continuous glucose monitoring device sensors for one (Patient #4) of 12 patients; 3. CHHA visit frequency for one (Patient #4) of 12 patients and; 4. SN wound site care related goals for one (Patient #6) of 12 patients. Findings: Patient #3 A review of the POC dated 12/01/23 to 01/29/24 showed a faxed physician’s order dated 12/27/23 attached to the clinical record. Documentation showed SN to perform monthly catheter changes using a 24 French/10 milliliter catheter. POC documentation showed no catheter treatment interventions, last changed or change due date and showed no SN goals related to indwelling urinary catheter management. Documentation of SN visits conducted between 12/28/23 and 01/02/24 showed no indwelling catheter treatment change intervention, patient/caregiver refusal of treatment, no physician notification and no changes in orders. On 01/04/24 at 2:00 p.m., Staff B stated the POC for patient #7 had no catheter treatment interventions, last changed or change due date and showed no SN goals related to indwelling urinary catheter management. Patient #4 A review of the POC dated 11/11/23 to 01/09/24 showed a SN visit frequency of one time a day for 60 days for SN to assess and instruct diabetic management to include glucometer use and preparation/administration of diabetic medications and showed no orders for CHHA visit frequency or interventions. POC medication profile documented Levimir 100 units/ml subcutaneous injection 16 units daily. Documentation showed no orders for SN to administer the Levimir daily or to change the continuous glucose monitoring sensor. Documentation showed SN visits were conducted daily from 11/11/23 to 01/01/24 (51 visits through date of the POC review) for SN to administer the Levimir daily and CHHA visits were conducted on 11/13/23, 11/16/23, 11/21/23, 11/30/23, 12/07/23, 12/16/23, 12/21/23 and on 12/28/23. A physicians order dated 01/02/24 documented for SN to administer Levimir daily. Documentation showed no physician notification of SN administering Levimir daily from 11/11/23 to 01/01/24 and no CHHA visits. On 01/04/24 at 2:20 p.m., Staff B stated the POC for patient #4 did not contain physician orders for the SN to administer the injection of Levimir daily or for CHHA visits. Patient #6 A review of the POC dated 11/12/23 to 01/10/23 showed a SN visit frequency of one time a week for nine weeks for SN to assess, instruct and perform wound site care to left great toe three times weekly. Documentation showed no related SN goals. Documentation showed no physician notification and no changes in orders. On 01/04/24 at 2:30 p.m., Staff B stated the POC for patient #6 did not contain related SN goals for wound care to the left great toe.

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. Physician ordered wound site care dressing materials for two (Patients #3 and #6) of 12 patients and; 2. OT evaluation and treatment plan for one (Patient #6) of 12 patients. Findings: Patient #3 A review of the POC dated 12/01/23 to 01/29/24 showed orders for SN to assess, instruct caregiver and perform wound site care to left heel with normal saline, apply silver alginate and cover with gauze dressing. Documentation showed during SN visits conducted on 12/03/23, 12/06/23, 12/07/23, 12/08/23 and on 12/20/23 SN applied calcium alginate dressing materials instead of silver alginate dressing materials. Documentation showed no physician notification and no changes in orders. On 01/04/24 at 2:00 p.m., Staff B stated the POC for patient #3 did not include calcium alginate dressing materials for the left heel wound site. Patient #6 A review of the POC dated 11/12/23 to 01/10/24 showed orders for SN to assess, instruct caregiver and perform wound site care to left great toe with normal saline, apply calcium alginate and cover with foam dressing. Documentation showed during SN visits conducted on 11/13/23 SN applied Medihoney to wound site in addition to calcium alginate and foam dressing. POC showed no physician order for OT evaluation and establishment of treatment plan. Documentation showed an OT evaluation was conducted on 11/21/23. Documentation showed no physician notifications and no changes in orders. On 01/04/24 at 2:30 p.m., Staff B stated the POC for patient #6 showed no notification of Medihoney for use during SN wound site care and showed no OT evaluation and treatment order.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care with facility care staff for one (Patient #5) of 12 patients. Findings: Patient #5 A review of the POC dated 12/13/23 to 02/10/24 showed orders for SN visit frequency one time a week for eight weeks. Documentation of a communication note dated 01/02/24 showed the patient experienced cough with lung congestion with a physician’s order to obtain a chest x-ray being noted. No SN visit note was available for review during the course of the survey through 01/04/24. Documentation showed no notification to the patient or ALF of an ordered chest x-ray. On 01/03/24 at 10:00 a.m., ALF staff #1 stated the patient had two chest x-rays on 01/02/24 because the agency did not notify the ALF staff that a chest x-ray had been arranged. The ALF staff stated they only became aware that the chest x-ray was being duplicated by the facility after their x-ray provider conducted the x-ray and the resident (patient) mentioned it. At 10:20 p.m., ALF staff #2 stated the agency nurse had left a coordination of care note in the facility in box but did not call the ALF nurse to give a report that a chest x-ray had been ordered by the physician. ALF staff #2 stated she had obtained a physician’s order and arranged the chest x-ray when the patient had complained to her of cough and congestion. At 10:30 a.m., Patient #5 stated he did not understand why he needed two chest x-rays on 01/02/24 and that the agency nurse did not tell him it was ordered by the physician during the SN visit. On 01/04/24 at 2:25 p.m., Staff B stated SN visit note was not completed from 01/02/24 because the SN was out sick and there was no documentation of coordination of care/services which showed the patient and ALF had been notified of an ordered and arranged chest x-ray for the patient.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure evidence of patient centered QAPI Program activities for all patients and employees. Findings: A review of agency QAPI Program documents showed no QAPI program improvement quarterly meeting activity, measurements, analysis, tracking or evaluation of data by the agency for calendar years 2022 and 2023. On 01/04/24 at 1:45 p.m., Staff B stated: 1. the agency did not meet quarterly and only prepared limited quarterly reports of data during calendar years 2022 and 2023; and 2. Documentation showed no improvement measurements, analysis, tracking or evaluation of data by the agency.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for calendar years 2022 and 2023 for all patients and employees. Findings: A review of QAPI Program documents showed limited PIP activities for calendar year 2022 and 2023. Documentation showed no intervention activities, analysis of data and showed no follow up or PIP status designation. On 01/04/24 at 1:45 p.m., Staff B stated the agency had no QAPI PIP records for calendar years 2022 and 2023 which showed intervention activities, analysis of data, follow up or PIP status designation.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2022 and 2023. On 01/04/24 at 1:40 p.m., Staff B stated documentation showed no evidence of multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for two (Patients #2 and #4) of 12 patients. Findings: Patient #2 A review of the POC dated 11/26/23 to 01/24/24 showed orders for showed a CHHA visit frequency of one time a week for eight weeks. A review of the clinical record showed CHHA supervisory visits were completed on 11/26/23 and 12/12/23 (16 days) and 12/12/23 and 12/28/23 (17 days). Documentation showed no change in orders, patient refusal or physician notification. On 01/04/24 at 1:50 p.m., Staff B stated the CHHA supervisory visits for Patients #2 should be conducted every 14 days. Patient #4 A review of the POC dated 11/11/23 to 01/09/24 showed no orders for CHHA visit frequency. Documentation showed CHHA visits completed 11/13/23, 11/16/23, 11/21/23, 11/30/23, 12/07/23, 12/16/23, 12/21/23 and 12/28/23 with supervisory visits completed on 11/27/23 and 12/12/23 (15 days between supervisory visits), 12/12/23 and 12/28/23 (16 days between supervisory visits). Documentation showed no change in orders, patient refusal or physician notification. On 01/04/24 at 2:20 p.m., Staff B stated the POC should have documented the CHHA visit frequency order and CHHA supervisory visits for Patients #4 should be conducted every 14 days.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. A patient centered QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2022 and 2023; and 3. Agency program evaluation for calendar years 2022 and 2023 effecting all patients and staff. Findings: A review of administrative records showed no governing body over-site and responsibility for the agency’s QAPI program, operating budget, capital expenditure plan or agency’s program evaluation for calendar years 2022 and 2023. On 01/04/24 at 1:30 p.m., Staff B stated documentation showed no administrative records which showed evidence of ongoing governing body oversite and responsibility for the agency’s QAPI program, operating budget, capital expenditure plan or agency’s program evaluation for calendar years 2022 and 2023.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit note documentation was complete for three (Patients #3, 5 and #6) of 12 patients. Findings: Patient #3 A review of the POC dated 12/01/23 to 01/29/24 showed orders for SN visit frequency of one week one, three week eight, then one week one. Documentation showed SN visit dated 12/27/23 showed as saved/incomplete status. SN documentation showed no wound site care was conducted. Documentation showed no physician notification and no changes in orders. On 01/04/24 at 2:00 p.m., Staff B stated SN visit documentation for 12/27/23 was incomplete. Patient #5 A review of the POC dated 12/13/23 to 02/10/24 showed orders for SN visit frequency one time a week for eight weeks. Documentation showed SN visit dated 12/28/23 was incomplete. Documentation showed no patient/caregiver refusal of care, physician notification of missed visit and no change in orders. On 01/04/24 at 2:25 p.m., Staff B stated SN should have conducted SN visit as ordered in the POC. Patient #6 A review of the POC dated 11/12/23 to 01/10/24 showed orders for SN visit frequency of one time a week for nine weeks. Documentation showed SN visit dated 12/25/23 was not started. Documentation showed no patient/caregiver refusal of care, no physician notifications of missed visit and no change in orders. On 01/04/24 at 2:30 p.m., Staff B stated the SN should have conducted SN visit as ordered in the POC.

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 one (Patient #10) of 12 patients. Findings: Patient #10 A review of the clinical record documented transfer from the agency on 12/07/23 to inpatient provider services with subsequent discharge from agency services. Documentation showed no transfer/discharge summary was provided to the inpatient service provider. On 01/04/24 at 2:42 p.m., Staff B stated no transfer/discharge summary was sent to the receiving service providers for Patient #10.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/08/21 to 02/11/21. 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 02/08/21 to 02/11/21. An entrance conference was conducted with Staff B. 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, B, C, D and E. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: DC Discharge HHA Home Health Aide OT Occupational Therapy PT Physical Therapy POC Plan of Care SN Skilled Nurse SNS Sterile Normal Saline

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 provided wound care as ordered for one (Patient #7); 2. SN visits were conducted as ordered for one (Patient #7); and 3. Occupational Therapy evaluation was completed for one (Patient #10) of 10 patients. Findings: Patient #7 A review of a POC dated 01/03/21 to 03/03/21 showed orders for SN to perform wound care two times a week to wound site #1 using SNS, calcium alginate and an occlusive dressing. A review of a clinical note dated 01/05/21 showed the wound care provided to wound site #1 was SNS followed by a gauze dressing. Documentation showed no physician notification or change in orders for wound site care and no patient or caregiver refusal to perform wound site care as ordered by the physician. An order dated 01/21/21 showed a change in wound care for wound site #1 and a SN frequency of three times a week. A review of clinical notes showed : 1) for the week of 01/24/21 to 01/30/21, two SN visits completed on 01/25/21 and 01/28/21 (one SN visit missed/unscheduled) and 2) for the week of 01/31/21 to 02/06/21, two SN visits completed on 02/01/21 and 02/04/21 (one SN visit missed/unscheduled). Documentation showed no physician notification or change in orders for wound site care and no patient or caregiver refusal to perform wound site care. Patient #10 A review of a POC dated 01/20/21 to 03/20/21 showed orders for OT to evaluate and treat. A review of clinical notes showed no OT evaluation scheduled or completed. Documentation showed no patient/caregiver refusal of visit, no missed visit note and no changes in the order to evaluate. On 02/11/21 at 12:00 p.m., Staff A stated: 1. The wound care performed on 01/05/21 for Patient #7 was not as ordered by the physician and the ordered SN visits were missed during the weeks of 01/24/21 to 01/30/21 and 01/31/21 to 02/06/21. 2. Patient #10 did not have an OT evaluation scheduled or completed.

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 notify the physician of changes in health conditions for one (Patient #5) of 10 patients. Findings: Patient #5 A POC dated 01/06/21 to 03/06/21 documented a principal diagnosis of hypertension with chronic kidney disease. A review of clinical notes dated 01/13/21, 01/28/21 and 02/04/21 documented: 1) the patient experienced a decrease in strength and endurance; 2) required assistance from a HHA for personal care; and 3) PT to increase strength and endurance. Documentation showed no physician notification of the patient's symptoms and no follow up communication with the agency of the patient's change in condition or change in service needs for visits completed on 01/13/21, 01/28/21 and 02/04/21. On 02/11/21 at 12:30 p.m., Staff A stated the SN should have notified the patient's physician of the change in condition and followed up with a coordination note to the agency documenting the patient's service needs during the home visits on 01/13/21, 01/28/21 and on 02/04/21.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure governing body over-site of the operating budget and allocation of resources for fiscal years 2019 and 2020 for 142 patients and all agency staff. Findings: A review of agency governing body minutes for fiscal years 2019 and 2020 showed no documentation the governing body provided over-site of the operating budget and allocation of resources for the agency in fiscal years 2019 and 2020. Additional documentation was requested. No further documentation was provided. On 02/09/21 at 2:34 p.m., Staff E stated the governing body members discussed the operating budget and resource allocation needs for the agency as ongoing issues but the documentation did not show resource allocation and operating budget needs were addressed.

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 discharge summaries were completed timely and were available for three (Patients #1, #2 and #3) of three patients. Findings: Patient #1 A review of the clinical record showed the patient was discharged from the agency on 10/08/20 to hospice care services. Documentation showed the discharge summary was completed on 10/13/20, sent to the physician on 11/03/20 and no discharge summary was provided to the hospice care service provider. Patient #2 A review of the clinical record showed the patient was transferred to in-patient hospital care on 01/20/21 and the patient was discharged from the agency to in-patient hospital care on 01/27/21. Documentation showed no transfer summary or discharge summary was provided to the hospital service provider. Patient #3 A review of the clinical record showed the patient was discharged from the agency on 10/09/20 to hospice care services. Documentation showed no discharge summary was provided to the hospice care service provider. On 02/11/20 at 12:30 p.m., Staff A stated: 1) no discharge summary was sent to the hospice service providers for Patient #1 and Patient #3; 2) no discharge summary was sent to the hospital for Patient #2; and 3) the discharge summary was not completed and sent to the physician timely for Patient #1.