Every finding on record at Healthcare Innovations of Western Oklahoma, L L C

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/23/24 to 01/24/24. Deficiencies were 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 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 01/24/24 at 2:30 p.m., Staff B stated the Emergency Preparedness Communication Plan did not include contact information for current staff of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 01/23/24 to 01/24/24. 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 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 survey. Glossary: ALF assisted living facility HHA Home Health Agency POC Plan of Care SN skilled nurse

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency, alternate service providers and physician for three (Patient #12, 14 and #15) of 18 patients. Findings: Patient #12 A review of a plan of care dated 12/22/23 to 02/19/24 documented a primary diagnosis of urinary tract infection. Documentation showed a physician order dated 01/18/24 for urine collection for urinalysis with culture. On 01/20/24 documentation showed a missed SN visit due to no urine collected (by the ALF staff). A coordination note dated 01/22/24 documented no urine had been collected as the ALF staff were not aware they were responsible to collect the urine sample. A SN note dated 01/23/24 documented the SN pick up the urine sample from the ALF and delivered the sample to the lab for processing. Documentation showed no coordination of care communications with the physician that the urine sample was not collected from 01/18/24 (date of the order) through 01/23/24 (date of sample pick up from the ALF) and showed no coordination of care with the ALF from 01/18/24 (date of the order) until 01/22/24 (date of coordination of care note). On 01/24/24 at 1:47 p.m., Staff A stated the physician for patient #12 should have had communications to ensure coordination of care between the physician and the ALF related to urinalysis sample collection for the patient. Patient #14 A review of a plan of care dated 07/28/23 to 09/25/23 documented a primary diagnosis of cognitive impairment. A physicians order dated 08/28/23 documented discharge from agency services to a hospice care service provider on 08/24/23. Documentation showed a PT discharge dated 08/28/23 (four days after the ordered discharge date). Documentation showed no coordination of care communications between the agency, PT service discipline, hospice service provider and to the physician that the patient was not discharge from agency services on 08/24/23. On 01/24/24 at 1:55 p.m., Staff A stated the physician for patient #14 should have had coordination of care communications to ensure coordination of care with the PT service discipline, hospice service provider and the physician that the patient was not discharge from agency services on 08/24/23. Patient #15 A review of a plan of care dated 12/23/23 to 02/20/24 documented a primary diagnosis of left lower extremity wound. Documentation showed a physician’s order dated 01/02/24 discharge to hospice service provider effective 12/31/23. Documentation showed a desk (non-visit) discharge on 01/01/24 (one day after the ordered discharge date). Documentation showed no coordination of care communications between the agency, hospice service provider and to the physician that the patient was not discharge from agency services on 12/31/23. On 01/24/24 at 2:02 p.m., Staff A stated the physician for patient #15 should have had coordination of care communications to ensure coordination of care with the agency, hospice service provider and the physician that the patient was not discharge from agency services on 12/31/23.

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 visits were conducted as ordered for one (Patients #12) of 18 patients; SN obtained a urine sample for one (Patient #12) of 18 patients and; SN conducted wound care as ordered for one (Patient #13) of 18 patients. Findings: Patient #12 A review of a plan of care dated 12/22/23 to 02/19/24 documented a primary diagnosis of urinary tract infection with a SN visit frequency of one week one, one every two weeks for two weeks, one week one, one every two weeks for two weeks, then one week two. Documentation showed during the week of 12/24/23 and 12/30/23 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed a physician order dated 01/18/24 for urine collection for urinalysis with culture. A SN visit note dated 01/23/24 documented pick up of the urine sample from the ALF and delivery of the sample to the lab for processing. Documentation showed no patient refusal of SN visits or urine collection and showed no coordination of care communications with the physician of missed SN visits or that the urine sample was not collected from 01/18/24 (date of the order) through 01/23/24 (date of sample pick up from the ALF). On 01/24/24 at 1:47 p.m., Staff A stated the during the week of 12/24/23 to 12/30/23 no SN visit was conducted and SN did not collect the urine sample from the patient as ordered on 01/18/24, the order did not state the urine sample was to be collected by the ALF staff and showed no coordination of care between the agency and the physician related to urinalysis sample collection for the patient. Patient #13 A review of a plan of care dated 12/28/23 to 02/25/24 documented a primary diagnosis of Diabetes mellitus Type II with foot ulcer; with a SN visit frequency of one week one, three week eight. SN visit notes dated 01/05/24 and 01/10/24 showed no documentation of wound care provided to the left great toe (ordered wound care was Vashe wound cleanser, apply Max org alginate and cover with a Tubigrip dressing and SN visit note dated 01/19/24 documented wound care provided to the left great toe was not the updated wound care ordered by the service provider on 01/18/24 (wound site cleanser, apply Prisma and cover with gauze dressing). Documentation showed no patient refusal of ordered wound care to the left great toe, no physician notification and no change in orders. On 01/24/24 at 1:50 p.m., Staff A stated SN did not document type of wound care performed during SN visits on 01/05/24 and 01/10/24 and SN did not perform updated (changed) wound care to the left great toe during SN visit on 01/19/24.

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 clinical visit note documentation was completed timely per agency policy for five (Patients #7, 8, 9, 10 and #11) of 18 patients. Findings: Patient #7 A review of the POC dated 12/14/23 to 02/11/24 showed orders for SN visit frequency of one week one, two week one, then one week seven. Documentation showed SN visit dated 01/09/24 was completed/submitted on 01/12/24 and SN visit dated 01/17/24 was completed/submitted on 01/22/24. Documentation showed no coordination of care related to delayed completion/submission of clinical visit notes. On 01/24/24 at 1:41 p.m., Staff A stated: 1. Clinical visit notes are due within 24 hours of the visit and; 2. SN visit documentation for 01/09/24 and 01/17/24 were not completed/submitted timely. Patient #8 A review of the POC dated 11/20/23 to 01/18/24 showed orders for SN visit frequency of one week two, one every two weeks for two weeks, one week one, one every two weeks for two weeks, then one week one. Documentation showed SN visit dated 12/07/23 was completed/submitted on 12/11/23, 12/19/23 was completed/submitted on 12/26/23, 01/09/24 was completed/submitted on 01/15/24 (SN and PT visit notes), 01/16/24 was completed/submitted on 01/22/24 and 01/18/24 was completed/submitted on 01/23/24. Documentation showed no coordination of care related to delayed completion/submission of clinical visit notes. On 01/24/24 at 1:42 p.m., Staff A stated: 1. Clinical visit notes are due within 24 hours of the visit and; 2. SN visit documentation for 12/07/23, 12/19/23, 01/09/24, 01/16/24, 01/18/24 were not completed/submitted timely. Patient #9 A review of the POC dated 12/21/23 to 02/13/24 showed orders for SN visit frequency of one week two, one every two weeks for two weeks, one week one, one every two weeks for two weeks, then one week two. Documentation showed SN visit dated 12/19/23 was completed/submitted on 12/26/23. Documentation showed no coordination of care related to delayed completion/submission of clinical visit notes. On 01/24/24 at 1:43 p.m., Staff A stated: 1. Clinical visit notes are due within 24 hours of the visit and; 2. SN visit documentation for 12/19/23 was not completed/submitted timely. Patient #10 A review of the POC dated 11/16/23 to 01/14/24 showed orders for SN visit frequency of one time a week for seven weeks. Documentation showed SN visit dated 12/13/23 was completed/submitted on 12/18/23, 12/21/23 was completed/submitted on 01/08/24 and SN visit dated 01/10/24 was completed/submitted on 01/15/24. Documentation showed no coordination of care related to delayed completion/submission of clinical visit notes. On 01/24/24 at 1:44 p.m., Staff A stated: 1. Clinical visit notes are due within 24 hours of the visit and; 2. SN visit documentation for 12/13/23, 12/21/23 and 01/10/24 were not completed/submitted timely. Patient #11 A review of the POC dated 12/26/23 to 02/23/24 showed orders for SN visit frequency of one time a week for nine weeks. Documentation showed SN visit dated 12/12/23 was completed/submitted on 12/18/23, 12/21/23 was completed/submitted on 12/26/23 and SN visit dated 01/16/24 was completed/submitted on 01/22/24. Documentation showed no coordination of care related to delayed completion/submission of clinical visit notes. On 01/24/24 at 1:46 p.m., Staff A stated: 1. Clinical visit notes are due within 24 hours of the visit and; 2. SN visit documentation for 12/12/23, 12/21/23 and 01/16/24 were not completed/submitted timely.

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 two (Patients #6 and #10) of 18 patients. Findings: Patient #6 A review of the POC dated 01/05/24 to 03/04/24 showed a SN visit frequency of one week two, one every two week two, one week one, one every two week two, then one time a week for one week. A physicians order dated 01/10/24 documented SN to remove and reapply surgical site dressing in four days. SN visit note dated 01/15/24 documented no removal and reapplication of a surgical site dressing. Documentation showed no patient refusal of care, no physician notification and no change in orders. On 01/24/24 at 1:40 p.m., Staff A stated the SN visit notes dated 01/19/24 for patient #6 showed no documentation of removal and reapplication of the surgical site dressing as ordered by the physician. Patient #10 A review of the POC dated 11/16/23 to 01/14/24 showed a SN visit frequency of one time a week for one week for SN to assess the patient’s weight and report to the physician weight less than 122 pounds and greater than 132 pounds. SN visit note dated 12/13/23 documented no weight assessment. Documentation showed no patient refusal, physician notification or change in orders. On 01/24/24 at 1:45 p.m., Staff A stated the SN visit notes dated 12/13/23 for patient #10 showed no documentation of assessment of the patient’s weight as ordered by the physician.

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: 1. To the receiving service provider for four (Patients #14, 15, 16 and #17) of 18 patients and; 2. To the physician within 5 days of discharge for four (Patients #14, 15, 16 and #18) of 18 patients. Findings: Patient #14 A review of the clinical record documented discharge from the agency to hospice service provider on 08/28/23. Documentation showed no discharge summary was provided to the receiving hospice service provider at the time of discharge and documentation showed the discharge summary was faxed to the physician on 09/06/23 (nine days after discharge). Patient #15 A review of the clinical record documented discharge from the agency to hospice service provider on 01/01/24. Documentation showed no discharge summary was provided to the receiving hospice service provider at the time of discharge and documentation showed the discharge summary was faxed to the physician on 01/17/24 (16 days after discharge). Patient #16 A review of the clinical record documented transfer to inpatient service provider with subsequent discharge from the agency on 11/14/23. Documentation showed no transfer/discharge summary was provided to the inpatient service provider and documentation showed the discharge summary was faxed to the physician on 01/05/24 (52 days after discharge). Patient #17 A review of the clinical record documented transfer to inpatient service provider on 12/03/23. Documentation showed no transfer summary was provided to the inpatient service provider or to the physician. Patient #18 A review of the clinical record documented discharge from the agency on 11/09/23. Documentation showed a discharge summary was provided to the physician on 11/15/23 (six days after discharge. On 01/24/24 at 1:55 p.m. to 2:10 p.m., Staff A stated: 1. No transfer/discharge summary was sent to the receiving service providers for Patients #14, 15, 16 and #17 and; No transfer/discharge summary was sent to the physician within 5 days of the transfer/discharge for Patients #14, 15, 16 and #18.