Every finding on record at Golden Age Health, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 01/06/26 to 01/08/26. 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 in conjunction with complaint #113634 at the agency from 01/06/26 to 01/08/26. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A and B were identified as contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, I, J and K. Standard level deficiencies were cited as a result of the survey. Glossary: POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse SOC start of care

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to: 1. Educate the patient on potential health outcomes related to refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance. 2. Notify the physician of the patient's continued refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance for one (Patient #8) of 15 patients. Findings: Patient #8 A review of a POC dated 12/29/24 to 02/26/25 showed a SN visit frequency of one time a week for nine weeks. A review of visit notes showed missed SN visits on 02/13/25, 02/18/25 and on 02/21/25 and showed a desk discharge for patient refusal of visits on 02/26/25. The clinical record showed no communication or education attempts to the patient for potential health outcomes related to refusal of and/or missed SN visits and showed no follow up communications to the physician of the patient's continued refusal of and/or missed SN visits prior to the patient’s discharge from the HHA. On 01/08/26 at 2:35 p.m., Staff A stated the clinical record showed no: 1. Attempts to educate the patient of potential health outcomes related to refusal of and/or missed SN visits. 2. Physician notification of the patient's continued refusal of and/or missed SN visits prior to the patient’s discharge from the agency.

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 to report to the physician or pain management goal for three (Patients #1, 5 and #6) of 15 patients.Weight management goal for one (Patient #1) of 15 patients.Wound management goal for one (Patient #2) of 15 patients. Findings: Patient #1 A review of the POC dated 11/08/25 to 01/06/26 showed orders for SN to assess and instruct the patient’s pain level and weight every visit. The POC showed no physician reporting parameters for the patient’s pain levels and showed no goals for the management of the patient’s pain and weight. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 1:45 p.m., Staff A stated the POC had no reporting parameters for the patients’ pain and had no goals for pain and weight management. Patient #2 A review of the POC dated 11/26/25 to 01/24/26 showed orders for SN to assess, instruct and conduct wound care interventions to the right lower extremity every visit. The POC showed no goals for wound management. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 1:55 p.m., Staff A stated the POC had no goals related to the wound care interventions. Patient #5 A review of the POC dated 11/30/25 to 01/28/26 showed orders for SN to assess and instruct the patient’s pain level every visit. The POC showed no physician reporting parameters for the patient’s pain levels. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 2:25 p.m., Staff A stated the POC had no reporting parameters for the patients’ pain. Patient #6 A review of the POC dated 11/14/25 to 01/12/26 showed orders for SN to assess and instruct the patient’s pain level every visit. The POC showed no physician reporting parameters for the patient’s pain levels. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 2:28 p.m., Staff A stated the POC had no reporting parameters for the patients’ pain.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program for calendar year 2023, 2024 and 01/01/25 to 04/03/25 for all patients and employees. Findings: A review of governing body meeting minutes showed no governing body oversite of the conduction of a patient centered QAPI program for: 2023 during a meeting on 02/28/23.2024 during a meeting on 05/09/24.01/01/25 to 03/30/25 during a meeting on 04/03/25. On 01/08/26 at 3:30 p.m., Staff A stated the meeting minutes do not document oversite of the QAPI program.

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: SN performed a foot assessment for one (Patient #1) of 15 patients.SN performed assessment of patient’s response to the medication for one (Patient #4) of 15 patients.SN monitored patient’s weight and reported weight greater than 125 pounds to the physician for one (Patient #6) of 15 patients. Findings: Patient #1 A review of the POC dated 11/08/25 to 01/06/26 showed orders for SN to perform an assessment of the patient’s feet every visit. A review of SN visit notes dated 11/12/25, 11/21/25, 12/08/25 and 12/15/25 showed no assessment of the patient’s feet and showed no patient or caregiver refusal, no physician notification and no changes in orders. On 01/08/26 at 1:45 p.m., Staff A stated the SN visit notes dated 11/12/25, 11/21/25, 12/08/25 and 12/15/25 did not document assessment of the patient’s feet. Patient #4 A review of the POC dated 12/06/25 to 02/03/26 showed orders for SN to assess the patient’s response to the medication Journavx (pain receptor inhibitor) every visit. A review of SN visit notes dated 12/09/25 and 12/31/25 showed no assessment of the patient’s response to the medication Journavx and showed no patient or caregiver refusal, no physician notification and no changes in orders. On 01/17/25 at 2:20 p.m., Staff A stated the SN visit notes dated 12/09/25 and on 12/31/25 did not document assessment of the medication. Patient #6 A review of the POC dated 11/14/25 to 01/12/26 showed orders for SN to assess and instruct the patients’ weight on every visit and report to the physician weight greater than 125 pounds. A review of SN visit notes showed on: 11/19/25 weight of 128.1 pounds12/03/25 weight of 127.8 pounds12/15/25 weight of 127.2 pounds12/22/25 weight of 127.8 pounds The SN visit notes showed no physician notification and no changes in orders. On 01/08/26 at 2:28 p.m., Staff A stated the SN visit notes dated 11/19/25, 12/03/25, 12/15/25 and 12/22/25 did not weight notifications to the physician.

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 certified home health aide supervisory visits were completed every 14 days for three (Patients #1, 2 and #4) of 15 patients. Findings: Patient #1 A review of the POC dated 11/08/25 to 01/06/26 showed orders for a CHHA visit frequency of one time a week for nine weeks. A review of the clinical record showed a CHHA supervisory visit was due on 12/29/25 and completed on 01/02/26 (18 days between supervisory visits) for CHHA visits on 12/16/25, 12/22/25 and 12/29/25. The supervisory visit notes showed no patient refusal of supervisory visits, no physician notification and no change in orders. On 01/08/26 at 1:45 p.m., Staff A stated the CHHA supervisory visit on 01/02/26 was late. Patient #2 A review of the POC dated 11/26/25 to 01/24/26 showed orders for showed a CHHA visit frequency of one time a week for nine weeks. A review of the clinical record showed a CHHA supervisory visit was due on 12/31/25 and completed on 01/02/26 (16 days between supervisory visits) for CHHA visits on 12/22/25 and 12/29/25. The supervisory visit notes showed no patient refusal of supervisory visits, no physician notification and no change in orders. On 01/08/26 at 1:55 p.m., Staff A stated the CHHA supervisory visit on 01/02/26 was late. Patient #4 A review of the POC dated 12/06/25 to 02/03/26 showed orders for showed a CHHA visit frequency of one time a week for eight weeks. A review of the clinical record showed a CHHA supervisory visit was due on 12/17/25 and completed on 12/23/25 (20 days between supervisory visits) for CHHA visits on 12/09/25 and 12/16/25. The supervisory visit notes showed no patient refusal of supervisory visits, no physician notification and no change in orders. On 01/08/26 at 2:20 p.m., Staff A stated the CHHA supervisory visit on 12/23/25 was late.

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 clinical visit note documentation was accurate for one (Patients #2) of 15 patients. Findings: Patient #2 A review of the POC dated 11/10/24 to 01/08/25 showed orders for SN to assess and conduct wound care interventions to right lower extremity wound sites each visit. SN visit notes dated 12/09/25 and 01/03/26 showed wound site interventions to left lower extremity were conducted during the visits. On 01/08/26 at 1:55 p.m., Staff A stated the SN visit notes on 12/09/25 and 01/03/26 documented wound site interventions to the left leg.

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 interviews, the agency failed to ensure completed transfer/discharge summaries were provided to receiving providers for four (Patients #8, 9, 11 and #12) of 15 patients. Findings: Patient #8 A review of the clinical record showed discharge from the agency on 02/26/25. The clinical record showed the discharge summary was provided to the ordering physician on 03/06/25 (8 days after discharge). On 01/08/26 at 2:25 p.m., Staff A stated the discharge summary was sent to the physician late. Patient #9 A review of the clinical record showed discharge from the agency on 08/18/25 to hospice services. The clinical record showed the discharge summary was not provided to the hospice provider. On 01/08/26 at 2:40 p.m., Staff A stated the discharge summary was not sent to the hospice provider. Patient #11 A review of the clinical record showed discharge from the agency on 12/16/25 to hospice services. The clinical record showed the discharge summary was not provided to the hospice provider. On 01/08/26 at 2:50 p.m., Staff A stated the discharge summary was not sent to the hospice provider. Patient #12 A review of the clinical record showed transfer with discharge from the agency on 12/05/25 to hospital services. The clinical record showed the transfer with discharge summary was completed on 12/17/25 and was not provided to the hospital provider. The transfer with discharge summary was sent to the ordering physician on 01/05/26 (19 days after discharge). On 01/08/26 at 2:55 p.m., Staff A stated the transfer with discharge summary was not sent to the hospital provider and was not sent to the physician late.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/05/22 to 12/06/22. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) identified an agency for which the assessment was developed and implemented for all patients and employees. Findings: A review of administrative records showed no documentation of a community-based risk assessment that identified the agency for which the assessment was developed and implemented for its patient population or employees. On 12/06/22 at 3:00 p.m., Staff B stated an AHRA outline located in an emergency preparedness manual did not identify the agency by name or provider number.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 12/05/22 to 12/06/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: CHHA certified home health aide HHA Home Health Agency Mg milligram POC Plan of Care SN Skilled Nurse

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Show documentation which impeded the HHA from providing care and services; 2. Educate the patient on potential health outcomes from discontinued HHA care and services; 3. Notify the physician the HHA was unable to provide care and services to meet the patient’s needs and; 4. Assist the patient and/or caregiver to choose an alternate entity to provide care and facilitate a safe patient transfer for one (Patient #10) of 13 patients. Findings: Patient #10 A review of a plan of care for 08/25/22 to 10/23/22 showed an SN visit frequency of two times a week for eight weeks and for SN to teach and train with observation and assessment of all systems with focus on wound care/wound management each visit. A review of clinical documentation showed a patient communication note dated 08/25/22 stated the patient was a quadriplegic and was unable to assist with her own care needs; was staying with a family member who could not assist the patient with care needs; and the case management department for the inpatient hospital service provider was notified the patient was not appropriate for HHA care and services after admission to the agency. A SN visit note dated 08/26/22 showed documentation the patient had received a notice of discharge and on 08/27/22 a discharge from agency was documented. The clinical record showed no documentation of how the patient’s situation had impeded the agency from providing care and services; showed no evidence the patient and/or caregiver had been educated about the patient’s care needs and how the HHA would not be able to meet those care needs; showed no alternate care choices had been presented to the patient to facilitate a safe transfer from the HHA; and show no documentation the physician had been notified that the HHA could not meet the patient’s care needs prior to the patient’s discharge from HHA. On 12/06/22 at 1:40 p.m., Staff A stated there was no documentation of: 1. Problems encountered by the HHA which impeded the HHA from providing care and services; 2. Patient education of potential health outcomes from discontinued HHA care and services; 3. Alternate care choices and facilitation of safe transfer from the agency was offered and; 4. Physician notification of the patient’s inadequate care environment and need for discharge from the HHA for inability to provide the patient with needed care and services for patient #10.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication profile was reviewed and updated with ordered medications for one (Patient #2) of 13 patients. Findings: Patient #2 A review of a POC dated 10/12/22 to 12/10/22 showed an order dated 10/19/22 for Pepcid AC every day and Aleve 220 mg in the morning. Documentation showed no update and review of the medications Pepcid and Aleve on the medication profile. On 12/06/22 at 12:35 p.m., Staff A stated the medication profile for Patient #2 should have been updated and reviewed for allergies and drug interactions with the addition of the medications.

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’s included: 1. Pain reporting parameters for two (Patients #2 and #3) of 13 patients; 2. Recurring urinary catheter change intervention treatment due dates were documented for one (Patient #4) of 13 patients and; 3. Recurring medication administration intervention treatment due dates were documented for two (Patients #6 and #8) of 13 patients. Findings: Patient #2 A review of the plan of care dated 10/12/22 to 12/10/22 documented a principal diagnosis of intervertebral disc degeneration of the thoracic region. Documentation showed physical therapy to assess and teach pain management techniques. Documentation showed no pain reporting parameters for physician notification of uncontrolled pain. On 12/06/22 at 12:35 p.m., Staff A stated the POC for Patient #2 should have documented pain reporting parameters for physician notification. Patient #3 A review of the plan of care dated 11/10/22 to 01/08/23 documented a principal diagnosis of stage 2 pressure ulcer to the left hip. Documentation showed SN to assess and teach pain management techniques. Documentation showed no pain reporting parameters for physician notification of uncontrolled pain. On 12/06/22 at 12:45 p.m., Staff A stated the POC for Patient #3 should have documented pain reporting parameters for physician notification. Patient #4 A review of the plan of care dated 10/25/22 to 12/23/22 documented a principal diagnosis of neurogenic bladder. POC orders directed SN to manage suprapubic catheter urinary device and perform treatment intervention of monthly catheter change. Documentation showed a last completed treatment intervention date of 07/01/2020. On 12/06/22 at 12:47 p.m., Staff A stated recurring urinary catheter treatment intervention change due dates should have been documented in the current POC episode dates for Patients #4. Patient #6 A review of the plan of care dated 10/03/22 to 12/01/22 documented a principal diagnoses of hypertensive heart failure. POC orders directed SN to administer Vitamin B12 one milliliter intramuscular injection every month. POC documentation showed no treatment intervention date the injection was due or last completed. On 12/06/22 at 12:52 p.m., Staff A stated recurring medication treatment intervention due dates for medication administration of Vitamin B12 should have been documented in the POC for Patients #6. Patient #8 A review of the plan of care dated 11/08/22 to 01/06/23 documented a principal diagnoses of Vitamin B12 anemia. POC orders directed SN to administer Vitamin B12 one milliliter intramuscular injection every month. POC documentation showed no treatment intervention date the injection was due or last completed. On 12/06/22 at 1:00 p.m., Staff A stated recurring medication treatment intervention due dates for medication administration of Vitamin B12 should have been documented in the POC for Patients #6.

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’s: 1. SN to conduct assessment of patient oxygen saturation level, record and report to the physician of change in patient oxygen saturation level outside of reporting parameters for one (Patients #1) of 13 patients; 2. SN to conduct visit frequency as ordered by the physician for two (Patients #3 and #13) of 13 patients; 3. SN to conduct assessment of patient blood pressure, record and report to the physician blood pressure levels outside of reporting parameters for one (Patient #5) of 13 patients; 4. SN to conduct assessment of patient weight monitor, record and report to the physician of change in patient weight outside of reporting parameters for two (Patients #6 and #8) of 13 patients and; 5. CHHA to conduct visit frequency as ordered by the physician for one (Patient #7) of 13 patients. Findings: Patient #1 A review of a plan of care dated 11/03/22 to 01/01/23 documented a primary diagnosis of hypertensive kidney disease with heart failure. Documentation showed SN to assess patient oxygen saturation level, record and report to the physician of change in patient oxygen saturation level outside of reporting parameters of less than 90%. Documentation showed no patient oxygen saturation level reading on SN visit dated 11/30/22. Documentation showed no patient/caregiver refusal of patient assessment of oxygen saturation level, no physician notification of declined oxygen saturation level monitoring and no change in orders. Patient #3 A review of a plan of care dated 11/10/22 to 01/08/23 documented a primary diagnosis of stage 2 pressure ulcer left hip. Documentation showed a SN visit frequency of one time a week for eight weeks. Documentation showed no SN visit during the week of 11/27/22 to 12/03/22 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of SN visit, no physician notification of declined SN visit and no change in orders. Patient #5 A review of a plan of care dated 10/11/22 to 12/09/22 documented a primary diagnosis of Diabetes Mellitus Type II. Documentation showed SN to assess patient blood pressure, record and report to the physician of change in patient blood pressure outside of reporting parameters of systolic pressure greater than 190. Documentation showed a blood pressure reading of 192/62 on SN visit dated 11/02/22. Documentation showed no physician notification of elevated systolic blood pressure level and no change in orders. Patient #6 A review of a plan of care dated 10/03/22 to 12/01/22 documented a primary diagnosis of hypertensive heart disease with heart failure. Documentation showed SN to monitor/record patient weight and report to physician weight less than 102 pounds. Documentation showed during SN visit dated 10/06/22 the patient’s weight was 94 pounds and on SN visit dated 10/21/22 the patient’s weight was 95.8 pounds. Documentation showed no physician notification of the patient’s weight levels below 102 pounds and no change in orders. Patient #7 A review of a plan of care dated 10/13/22 to 12/11/23 documented a primary diagnosis of COVID respiratory failure. Documentation showed an updated POC dated 10/23/22 with a CHHA visit frequency of one time a week for seven weeks. Documentation showed no CHHA visit during the week of 10/23/22 to 10/29/22 (one visit ordered, no visit conducted); 10/30/22 to 11/05/22 (one visit ordered, no visit conducted); 11/06/22 to 11/12/22 (one visit ordered, no visit conducted); 11/13/22 to 11/19/22(one visit ordered, no visit conducted); 11/20/22 to 11/26/22 (one visit ordered, no visit conducted); and 11/27/22 to 12/03/22 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of CHHA visits, no physician notification of declined CHHA visits and no change in orders. Patient #8 A review of a plan of care dated 11/08/22 to 01/06/23 documented a primary diagnosis of anemia. Documentation showed SN to monitor/record patient weight and report to physician weight less than 165 pounds. Documentation showed during SN visit dated 11/16/22 the patient’s weight was 162 pounds. Documentation showed no physician notification of the patient’s weight levels below 165 pounds and no change in orders. Patient #13 A review of a plan of care dated 10/26/22 to 12/23/22 documented a primary diagnosis of Diabetes Mellitus Type II. Documentation showed a SN visit frequency of two times a week for nine weeks. Documentation showed no SN visit during the week of 10/30/22 to 11/05/22 (two visits ordered, no visits conducted). Documentation showed no patient/caregiver refusal of SN visit, no physician notification of declined SN visit and no change in orders. On 12/06/22 at 12:30 p.m., Staff A stated: 1. SN should have conducted assessment of patient oxygen saturation levels for patient #1; 2. SN should have conducted SN visits as ordered for patients #3 and #13; 3. SN should have reported to the physician blood pressure levels outside of the reporting parameter for patient #5; 4. SN should have report to the physician changes in patient weight outside of reporting parameters for patients #6 and #8 and; 5. SN should have conducted CHHA visits as ordered for patient #7.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit notes were completed for two (Patients #1 and #5) of 13 patients. Findings: Patient #1 A review of a plan of care dated 11/03/22 to 01/01/23 documented a primary diagnosis of hypertensive kidney disease with heart failure. Documentation showed a SN visit frequency of once a week for eight weeks. Documentation showed SN visits note dated 11/30/22 was not completed and authenticated by the SN. On 12/06/22 at 12:30 p.m., Staff A stated visit notes are to be completed and signed by staff within 24 hours of the visit and submitted to the clinical record within 14 days of the visit date and the note was incomplete. Patient #5 A review of a plan of care dated 10/11/22 to 12/09/23 documented a primary diagnosis of Diabetes Mellitus Type II. Documentation showed SN visit frequency of five times a week for one week, seven times a week for seven weeks, and then six times a week for one week. Documentation showed SN visit notes dated 11/01/22, 11/22/22, 11/23/22, 12/02/22 and on 12/02/22 were “not started” in the electronic clinical record documentation system and were not completed or authenticated by the SN who conducted the visits. On 12/06/22 at 12:50 p.m., Staff A stated visit notes are to be completed and signed by staff within 24 hours of the visit and submitted to the clinical record within 14 days of the visit date and the note was incomplete.

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 #8 and #9) of 13 patients. Findings: Patient #8 A plan of care dated 11/08/22 to 01/06/23 showed a CHHA visit frequency of once a week for nine weeks. A review of the clinical record showed CHHA visits were conducted on 11/18/22 and on 12/02/22 with a supervisory visit completed on 11/16/22. Documentation showed an incomplete CHHA supervisory visit was conducted on 11/30/22 but not documented (19 days from date of aide supervisory visit on 11/16/22). Documentation showed no patient/caregiver refusal of the supervisory visit, physician notification of missed visits or change in orders. On 12/06/22 at 1:00 p.m., Staff A stated the CHHA supervisory visits for patient #8 should have been completed by 11/30/22 to meet the every 14 days supervisory requirement. Patient #9 A plan of care dated 10/10/22 to 12/08/22 showed a CHHA visit frequency of once a week for nine weeks. A review of the clinical record showed CHHA visits were conducted on 10/12/22, 10/19/22, 10/26/22. 11/02/22, 11/09/22, 11/16/22 and on 11/23/22; with CHHA supervisory visits conducted on 10/21/22 and on 11/11/22 (21 days between supervisory visits). Documentation showed no patient/caregiver refusal of the supervisory visit, physician notification or change in orders. On 12/06/22 at 1:05 p.m., Staff A stated the CHHA supervisory visit for patient #9 should have been completed every 14 days.

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 summary was provided for one (Patients #1) of 13 patients. Findings: Patient #1 A review of the clinical record documented transfer from the agency on 11/02/22 to inpatient hospital provider services. Documentation showed a transfer summary was completed on 11/07/22 (5 days after notification was received the patient was admitted to inpatient services) and no transfer summary was provided to the inpatient hospital services provider. On 12/06/22 at 12:30 p.m., Staff A stated a transfer summary for patient #1 was completed late and no transfer summary was sent to the receiving service provider.