Every finding on record at Health Watch Health Care of Duncan, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program at the Agency 01/21/26 - 1/22/26. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. A deficiency was cited as a result of the Emergency Preparedness Program Survey.

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 a phone list had contact information for current employees for all 185 patients and employees. Findings: A review of the Emergency Preparedness Program showed a list of staff names and telephone numbers. The current administrator and alternate administrator's names and telephone numbers did not appear on the list. On 01/22/26 at 11:00 a.m., Staff B stated the administrator, and alternate administrator's names and telephone numbers did not appear on the list.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency 01/21/26 - 01/22/26. An entrance conference was conducted with Staff A. Staff B and C were identified as the contact persons for administrative issues and Staff A was identified for clinical issues. Findings were discussed 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 Pt - Patient RN - Registered Nurse

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial start of care assessments were completed within 48 hours of referral for two (Pt #5 and 10) of thirteen patients. Findings: Pt #5 A physician's order dated 11/10/25 ordered the start of care effective 11/12/25. Clinical documentation showed the start of care assessment completed 11/13/25. The clinical record showed no refusal by the patient or caregiver for a start of care within 48 hours of referral, no physician's order for a delayed start of care, and no coordination note why the admission was completed three days after the referral and a day after the ordered start of care. Pt#10 Clinical documentation showed a referral received 07/30/25 and no initial start of care assessment until 08/02/25. The clinical record showed no refusal by the patient or caregiver for a start of care within 48 hours of referral, no physician's order for a delayed start of care, and no coordination note why the admission was completed three days after the referral. On 01/22/26 at 11:52 a.m., Staff be stated there is no reason documented for the start of care assessments not being completed within 48 hours of referral.

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 a current POC was provided assisted living facilities for three (Pt #4, 5, and 6) of six patients residing in an assisted living facilities. Findings: Pt #4 A review of the home health agency record at the assisted living showed no current plan of care for the certification period of 01/13/26 - 03/13/26. The only plan of care available was dated 09/14/25 - 11/12/25. Pt #5 A review of the home health agency record at the assisted living showed no plan of care for the certification period of 01/11/26 - 03/11/26. Pt #6 A review of the home health agency record at the assisted living showed no current plan of care for the certification period of 12/14/25 - 02/11/26. The only plan of care available was dated 10/15/25 - 12/13/25. On 01/22/26 at 08:50 a.m., Assisted Living Staff E stated we do not have a current plan of care for Pt # 6. On 01/22/26 at 09:30 a.m., Assisted Living Staff D stated we do not have a current plan of care for Pt #4 and 5.

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 the CHHA supervisory visits were completed for one (Pt # 6) of 5 patients receiving CHHA services. Findings: Pt #6 A plan of care dated 12/14/25 - 02/11/26 showed orders for a CHHA once a week for nine weeks. Documentation showed an RN supervisory visit completed 12/29/25. No other supervisory visits were completed through 01/22/26 (one should have been completed 01/12/26). On 01/22/26 at 12:00 p.m., Staff A stated only one supervisory visit had been completed since 12/14/25.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/26/23. 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 01/26/23. 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, B, C, D, E and F. Standard level deficiencies were cited as a result of the survey. Glossary: HHA Home Health Agency OT Occupational 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 an advance notice of discharge was provided prior to being discharged from the agency for one (Patient #10) of 10 patients. Findings: Patient #10 A review of the clinical record showed the patient was discharged from the agency on 01/03/23 for a change in payer source and showed no documentation of an advance notice of discharge prior to discharge from the agency. On 01/26/23 at 5:15 p.m., Staff A stated Patient #10 received no advance notice of discharge prior to discharge from agency 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 an individualized patient POC included treatment intervention due date or treatment intervention last conducted date for one (Patient #5) of 10 patients. Findings: Patient #5 A review of a POC dated 11/24/22 to 01/22/23 showed orders for a SN visit frequency of one time a week for eight weeks for SN to administer Vitamin B12 intramuscular injection monthly. Documentation showed no treatment intervention due date or treatment intervention last conducted date, no physician notification and no change in orders. On 01/26/23 at 5:02 p.m., Staff A stated the POC did not contain a treatment intervention due date or treatment intervention last conducted date.

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: 1. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for three (Patients #1, 4 and #6) of 10 patients and; 2. SN to administer Vitamin B12 intramuscular injection monthly for one (Patient #1) of 10 patients. Findings: Patient #1 A review of the POC dated 12/22/22 to 2/19/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit and notify the physician of change in patient weight and SN to administer Vitamin B12 intramuscular injection monthly. Documentation showed no assessment and monitoring of the patient’s weight was conducted during SN visits on 12/28/22 and on 01/16/23, and documentation showed no Vitamin B12 intramuscular injection was administered during SN visit on 12/28/22 or during subsequent SN visits on 01/03/23 and 01/16/23. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits on 12/28/22 and 01/16/23, no patient/caregiver refusal of B12 intramuscular injection on 01/03/23 or on 01/16/23, no physician notifications and no change in orders. On 01/26/23 at 4:35 p.m., Staff A stated the SN should have been conducted assessment and monitoring of the patient’s weight every visit and the monthly intramuscular injection should have been administered as ordered by the physician. Patient #4 A review of the POC dated 11/29/22 to 01/23/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit and notify the physician of change in patient weight. Documentation showed no assessment and monitoring of the patient’s weight was conducted during SN visits on 12/01/22 and on 12/08/22. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 01/26/23 at 5:00 p.m., Staff A stated the SN should have been conducted assessment and monitoring of the patient’s weight every visit as ordered by the physician. Patient #6 A review of the POC dated 12/10/22 to 02/07/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit and notify the physician of change in patient weight. Documentation showed no assessment and monitoring of the patient’s weight was conducted during SN visits on 12/14/22, 12/16/22, 12/19/22, 12/22/22, 12/24/22, 12/29/22, 01/05/23, 01/07/23, 01/13/23, 01/16/23, 01/19/23, 01/20/23, 01/21/23, 01/22/23 and on 01/23/23. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 01/26/23 at 5:05 p.m., Staff A stated the SN should have been conducted assessment and monitoring of the patient’s weight every visit as ordered by the physician.

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 OT visit notes were completed for one (Patient #2) of 10 patients. Findings: Patient #2 A plan of care dated 01/04/23 to 03/04/23 documented a principal diagnosis of congestive heart failure. Documentation showed an OT visit frequency of one time a week for nine weeks. Documentation showed an OT visit note on 01/18/23 was not started, completed, authenticated or submitted by the OT. On 01/26/23 at 4:50 p.m., Staff A stated visit notes are to be completed and submitted by staff within 48 hours (two days) of the visit.

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 to receiving health care service providers for two (Patients #9 and #10) of 10 patients. Findings: Patient #9 A review of the clinical record documented discharge from the agency on 12/21/22 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #10 A review of the clinical record documented discharge from the agency on 01/03/23 for a change in payer source. Documentation showed no discharge summary was provided to the physician service provider. On 01/05/23 at 5:15 p.m., Staff A stated: 1. No discharge summary was sent to the receiving service provider for Patient #9 and; 2. No discharge summary was sent to the physician for Patient #10.