Every finding on record at Healthcare Innovations - Travertine Health Services, L.L.C.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 08/06/25 to 08/07/25. 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 current employee contact information for the agency for 50 patients and 107 employees. Findings: A review of the Emergency Preparedness Communication Plan showed former employee contact information and was not updated to include current employee contact information for some staff for the agency. On 08/07/25 at 4:00 p.m., Staff B stated the Emergency Preparedness Communication Plan was not updated to include: 1. Removal of contact information for former employees of the agency. 2. Contact information for some of the current employees of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency from 08/06/25 to 08/07/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as a contact person for administrative and clinical issues and Staff B was identified as an additional contact person for administrative and clinical issues Findings were discussed during an informal exit conference with Staff A, B, C, D, E, F, G, H and I. Standard level deficiencies were cited as a result of the survey. Glossary: PT physical therapy POC Plan of Care SN skilled 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 an initial assessment was conducted within 48 hours of referral for two (Patients #5 and #7) of 11 patients. Findings: Patient #5 A review of the clinical record showed the agency received referral information on 02/28/25 and the initial assessment occurred on 03/03/25. Documentation showed no patient refusal of initial assessment, no physician notification of a delay in initial and no change in orders. On 08/07/25 at 3:10 p.m., Staff A stated: The delay in the initial assessment was not documented in the clinical record.Any delay in the initial assessment should have been documented in the clinical record.The initial assessment should have been conducted by 03/02/25. Patient #7 A review of the clinical record showed the agency received referral information on 01/09/24 and the initial assessment occurred on 01/12/24. Documentation showed no patient refusal of initial assessment, no physician notification of a delay in initial and no change in orders. On 08/07/25 at 3:38 p.m., Staff A stated: The delay in the initial assessment was not documented in the clinical record.Any delay in the initial assessment should have been documented in the clinical record.The initial assessment should have been conducted by 01/11/24.

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: 1. SN medication administration treatment/interventions due date or last changed treatment date for one (Patient #1) of 11 patients. 2. SN catheter treatment/interventions due date or last changed treatment date for urinary catheter management for one (Patient #6) of 11 patients. Findings: Patient #1 A review of the POC dated 05/27/25 to 07/25/25 showed orders for SN to administer B12 subcutaneous injections weekly. The POC showed no medication administration treatment/intervention due date or last administered treatment date. On 08/07/25 at 2:42 p.m., Staff A stated the POC should have included medication administration treatment/intervention due date or last administered treatment date for patient #1. Patient #6 A review of the POC dated 06/14/25 to 08/12/25 showed orders for SN to conduct Coude 18 French/10 cubic centimeters catheter change every month. The POC showed no catheter treatment/interventions due date or last changed treatment date, no physician notifications and no change in orders. On 08/07/25 at 3:27 p.m., Staff A stated the POC should have included Coude catheter intervention last changed or monthly change due date for patient #6.

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/medical provider orders were transcribed correctly as a part of the patient’s POC for one (Patient #4) of 11 patients. Findings: Patient #4 A review of the POC dated 06/29/25 to 08/27/25 showed orders for SN to conduct wound care to left heel each visit. The wound care order dated 07/09/25 stated: SN to cleanse wound site to the left heel with normal saline, pat dry, apply calcium alginate and bordered foam dressings two times a week. SN visit notes dated 07/11/25, 07/14/25, 07/23/25 and on 07/25/25 showed wound site care was conducted to the right heel. The SN visit notes showed no physician/medical provider notification, coordination of care communications and no written order to change the wound site care to the right heel. On 08/07/25 at 3:04 p.m., Staff A stated: 1. The transcribed wound care order did not document the correct anatomical location of the wound site. 2. A correction order should have been obtained from the medical provider and entered into the clinical record.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 and physician/medical provider for two (Patient #4 and #5) of 11 patients. Findings: Patient #4 A review of the POC dated 06/29/25 to 08/27/25 showed orders for a SN to assess, monitor and instruct health conditions and SN to report blood sugar level greater than 180 each visit. SN visit notes dated: · 07/08/25 showed a BS of 256 · 07/09/25 showed a BS of 185 · 07/13/25 showed a BS of 394 · 07/15/25 showed a BS of 374 · 07/17/25 showed a BS of 255 · 07/27/25 showed a BS of 251 · 07/28/25 showed a BS of 277 · 08/04/25 showed a BS of 219 · 08/05/25 showed a BS of 236 The SN visit notes documented results were “auto faxed to physician” and showed no follow up physician communications or coordination of care notes for continued blood sugar levels elevated above 180. On 08/07/25 at 3:04 p.m., Staff A stated the agency did not follow up with the physician that the patient’s blood sugar levels continued to be out of the reporting parameters. Patient #5 A review of the POC dated 07/01/25 to 08/29/25 showed orders for: · SN to assess, monitor and instruct health conditions · Administer Humalog 5-unit insulin subcutaneously every day · Perform fingerstick blood sugar every visit, report and hold Humalog 5-unit insulin injectable medication for blood sugar levels less than 150 SN visit notes dated 07/01/25, 07/02/25, 07/03/25, 07/04/25, 07/05/25, 07/06/25, 07/07/25, 07/08/25, 07/10/25, 07/11/25, 07/18/25, 07/19/25, 07/20/25 and on 07/21/25 showed Humalog insulin 5u daily injections were withheld for blood sugar levels less than 150. The SN visit notes showed no follow up physician communications or coordination of care notes notifying the physician/medical provider that the patient continued to have blood sugar levels less than 150 and that the daily Humalog injections were withheld. On 08/07/25 at 3:10 p.m., Staff A stated the agency did not follow up with the physician to inform the patient’s blood sugar levels continued to be out of the reporting parameters and that the daily Humalog 5-unit daily dose injections were withheld.

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: 1. SN administered medication as ordered for one (Patient #1) of 11 patients. 2. SN conducted visits as ordered for three (Patients #1, 2 and #6) of 11 patients. 3. PT conducted visits as ordered for one (Patient #6) of 11 patients. Findings: Patient #1 A review of the POC dated 05/27/25 to 07/25/25 showed orders for SN visit frequency of one time a week for nine weeks to administer Vitamin B12 subcutaneous injections every visit. During the week of 06/08/25 to 06/14/25 a SN communication note showed: · A missed visit dated 06/12/25 (one visit ordered, no visit conducted). · No attempts to reschedule the missed visit · Showed no physician notification the medication was not administered and no changes in the orders. On 08/07/25 at 2:42 p.m., Staff A stated: 1. The SN visits were not conducted as ordered on the POC. 2. The SN visit should have been rescheduled for medication administration on another day. 3. The physician should have been notified the medication was not administered due to the missed SN visit. Patient #2 A review of the POC dated 06/09/25 to 08/08/25 showed orders for SN visit frequency of one time a week for nine weeks for SN to administer Ozempic (a diabetic medication) 0.25 milligram subcutaneously weekly on Fridays. SN visit notes dated 06/19/25, 06/26/25, 07/03/25, 07/17/25, 07/24/25 and on 07/31/25 showed the SN visits and the medication injections were conducted weekly on Thursdays. The clinical record showed no physician notification the medication was not administered as ordered and showed no changes in the orders. On 08/07/25 at 2:50 p.m., Staff A stated: 1. The SN visits were not conducted as ordered on the POC. 2. The physician should have been notified that the medication was not administered as ordered on the POC. Patient #6 A review of the POC dated 06/14/25 to 08/12/25 showed orders for SN visit frequency of one time a week for four weeks, then one time every two weeks for four weeks and a PT evaluation, once a week for one-week due week of 06/15/25. A PT communication note dated 06/20/25 showed the PT evaluation was missed due to “caregiver provided care” (one visit ordered, no visit conducted). The PT communication note showed no attempt to reschedule the visit, no physician notification and no change in the orders. A physician’s order dated 06/25/25 documented PT evaluation, once a week for one-week due week of 06/30/25. A PT missed visit note dated 07/02/25 showed the PT evaluation was missed due to “patient requested care next week” (one visit ordered, no visit conducted). The PT missed note showed no attempt to reschedule the visit, no physician notification and no change in the orders. A physician’s order dated 07/06/25 documented PT evaluation, once a week for one-week due week of 07/07/25. During the week of 07/06/25 to 07/12/25 the clinical record showed no SN visit was scheduled or conducted (one visit ordered, no visit conducted) and no PT evaluation visit was scheduled or conducted (one visit ordered, no visit conducted). The clinical record showed no physician notification of the missed visits and no change in the orders. On 08/07/25 at 3:27 p.m., Staff A stated the SN and PT evaluation visits were not conducted as ordered on the POC.

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 the agency’s program evaluation, operating budget, and capital expenditure plan for calendar year 2024 for all patients and employees. Findings: A review of administrative records (governing body meeting minutes) showed no governing body oversite of the agency’s annual program evaluation, operating budget and capital expenditure plan for calendar year 2024. On 08/07/25 at 4:00 p.m., Staff B stated the governing body meeting minutes had no governing body oversite for the agency’s program evaluation, operating budget and capital expenditure plan for calendar year 2024.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure chronic disease management assessment, monitoring and teaching interventions were provided within professional standards of practice for an assigned skilled professional for one (Patient #3) of 11 patients. Findings: A review of the State of Oklahoma Speech-Language Pathology and Audiology Licensing Act Title 59. Professions and Occupations; 59-1603 showed the following: "(9) practice of speech-language pathology means the rendering or offering to render any person or public speech, voice, social communication, cognitive communication, feeding or swallowing or habilitation and rehabilitation of or for persons who have or are suspected of having speech, voice, feeding or swallowing or language disorder…services may also be provided for…forms of communication enhancement." A review of the American Speech-Language-Hearing Association (ASHA) showed the following: "Scope of Practice in Speech-Language Pathology 2016; Treatment: Speech-language services are designed to optimize individuals’ ability to communicate and swallow… SLPs (Speech Language Pathologist) develop and implement treatment to address symptoms or concerns of a communication or swallowing problem or related functional issue." Patient #3 A review of a POC dated 06/13/25 to 08/11/25 showed orders for Speech Therapy to assess and evaluate co-morbid conditions of heart failure and coronary arterial disease and provide ongoing monitoring for changes in health status, treatment regimen and medication regimen. Speech Therapy to provide teaching and reinforcement of heart failure best practices including vital sign monitoring (blood pressure, pulse and respirations), daily weight, medication adherence, heart failure management zones (disease management teaching materials), nutrition, managing dyspnea and increasing activity for living with heart failure. A review of a personnel record for Staff M showed: 1. A signed job description for ST dated 10/05/21 stated: · Review and update patient compliance, understanding of medication regimen contraindications and side effects. · Report need for add on services to appropriate branch staff. 2. A skills checklist dated 10/29/21 showed no extended or continued education related to pharmacological medical management of medications used for heart failure and coronary heart disease processes. 3. A continuing education transcript showed no basic or extended training on the pathophysiological, cause/effect or interventional management related to heart failure and coronary heart disease processes. On 08/07/25 at 2:55 p.m., Staff A stated the ST: 1. ST’s are not licensed to identify, intervene or treat patients on disease management processes unrelated to speech, swallowing and communication. 2. The nursing service discipline was not recommended by the ST to teach disease management of heart failure and coronary arterial disease.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN and PT visit notes were completed within 48 hours of the visit for one (Patient #6) of 11 patients. Findings: Patient #6 A review of the POC dated 06/14/25 to 08/12/25 showed orders for SN and PT visits. A PT visit note showed a visit dated 07/15/25 was completed on 07/21/25 (6 days after the visit). A SN visit note showed a visit dated 07/25/25 was completed on 07/28/25 (3 days after the visit). On 08/07/25 at 3:27 p.m., Staff A stated: 1. Visit note documentation is due 48 hours from the time a visit is completed. 2. The PT visit note documentation should have been completed by 07/17/25 and the SN visit note should have been completed by 07/27/25.

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 discharge summaries were provided to receiving service providers for two (Patients #8 and #10) of 11 patients. Findings: Patient #8 A review of the clinical record showed a discharge from the agency on 06/03/25 to hospice provider services. The clinical record showed no coordination of care or discharge summary was provided to the receiving hospice service provider. On 08/07/25 at 3:40 p.m., Staff A stated: 1. The clinical record showed no coordination of care with the hospice service provider. 2. The discharge summary was not provided to hospice service provider. Patient #10 A review of the clinical record showed a discharge from the agency on 07/25/25. The clinical record showed the discharge summary was not provided to the physician/medical provider until 07/31/25 (six days). On 08/07/25 at 3:40 p.m., Staff A stated the discharge summary was not provided to physician/medical provider within five days of the discharge.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 09/13/22 to 09/15/22. 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 09/13/22 to 09/15/22. An entrance conference was conducted with Staff A, B and C. 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 Medicare re-certification survey. Glossary: ABN advance beneficiary notice FSBS finger stick blood sugar HHA home health agency PT physical therapy 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 reviews and interview, the agency failed to ensure a transfer/discharge summary was completed at the time of patient transfer/discharge for two (Patient #3 and #5) of 17 patients. Findings: Patient #3 A review of the clinical record showed the patient was transferred from the agency on 09/06/22 to in-patient hospital provider services. Documentation showed no transfer or discharge summary was completed. On 09/15/22 at 9:25 a.m., Staff A stated the clinical record showed no transfer summary of care for patient #3. Patient #5 A review of the clinical record showed the patient was transferred from the agency on 08/09/22 to in-patient hospital provider services. Documentation showed no transfer summary was completed. On 09/15/22 at 9:33 a.m., Staff A stated the clinical record showed no transfer summary of care for patient #5.

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 beneficiary notice was provided prior to being discharged from the agency to three (Patient #15, 16 and #17) of 17 patients. Findings: Patient #15 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 04/27/22. On 09/15/22 at 10:05 a.m., Staff A stated: 1. There was no ABN notice in the clinical records for Patient #15 and; 2. Patient #15 should have received a notice of discharge prior to being discharged from the agency. Patient #16 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 05/24/22. On 09/15/22 at 10:10 a.m., Staff A stated: 1. There was no ABN notice in the clinical records for Patient #16 and; 2. Patient #16 should have received a notice of discharge prior to being discharged from the agency. Patient #17 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 06/15/22. On 09/15/22 at 10:15 a.m., Staff A stated: 1. There was no ABN notice in the clinical records for Patient #17 and; 2. Patient #17 should have received a notice of discharge prior to being discharged from the agency.

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 educate the patient and/or a patient caregiver on potential health outcomes related to refusal of HHA provider services for two (Patient #16 and #17) of 17 patients. Findings: Patient #16 A review of a plan of care for 03/24/22 to 05/22/22 showed an SN visit frequency of one times a week for nine weeks; a PT visit frequency of two times a week for one week, then one time a week for four weeks; and an OT visit frequency of two times a week for three weeks, then one time a week for one week. A review of visit notes showed the patient was not available to schedule HHA visits on 03/28/22, 04/04/22, 04/06/22 and on 05/18/22 with a subsequent discharge from agency services on 05/24/22. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of HHA provider service and no documentation to the physician of the patient's continued non-availability for HHA visits prior to the discharge date of 05/24/22. On 09/15/22 at 10:10 a.m., Staff A stated there was no documentation of: 1. Attempts to educate the patient and/or patient caregiver of potential health outcomes related to refusal of HHA services and; 2. No physician notification of the patient's non-availability for HHA visits prior to discharge from the agency for non-compliance. Patient #17 A review of a plan of care for 05/12/22 to 07/10/22 showed an SN visit frequency of one times a week for seven, then one time a week every two weeks for two weeks and a PT visit frequency of two times a week for four weeks. A review of visit notes showed the patient was not available for SN visits on 05/25/22, 05/27/22 and on 06/08/22; and missed PT visits on 05/19/22, 05/24/22, 05/26/22, 06/01/22 and on 06/02/22 with a subsequent discharge from agency services on 06/15/22. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal (non-compliance) of HHA provider service and no documentation to the physician of the patient's continued non-compliance with HHA visit frequencies prior to the discharge date of 06/15/22. On 09/15/22 at 10:10 a.m., Staff A stated there was no documentation of: 1. Attempts to educate the patient and/or patient caregiver of potential health outcomes related to refusal of HHA services and; 2. No physician notification of the patient's non-availability for HHA visits prior to discharge from the agency for non-compliance.

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 the individualized patient POC included: 1. Sliding scale insulin medication for one (Patient #2); 2. Wound care supplies no longer in use for one (Patient #4) and; 3. Recurring urinary catheter change due dates for one (Patient #5) of 17 patients. Findings: Patient #2 A review of the plan of care dated 09/02/22 to 10/31/22 documented a principal diagnosis of Diabetes Mellitus Type II. POC orders instructed: SN to perform FSBS for signs and symptoms of hyper/hypoglycemia and administer insulin as needed. Documentation showed the POC did not include insulin medication type or dose parameters. On 09/15/22 at 9:15 a.m., Staff A stated the POC should have included the insulin medication type and dose parameters for patient #2. Patient #4 A review of the plan of care dated 08/31/22 to 10/29/22 documented a principal diagnosis of stage III pressure ulcer. Documentation showed the POC contained no orders for wound site care, as the wound site was healed. Documentation showed wound care supplies from previous wound site care was not removed from the POC at the time of service recertification. On 09/15/22 at 9:30 a.m., Staff A stated the POC should not have included the wound care supplies from the previous certification period for patient #2. Patient #5 A review of the plan of care dated 07/31/22 to 09/28/22 documented a principal diagnosis of stage III pressure ulcer. POC orders instructed SN to change indwelling Foley catheter every month. POC documentation showed no treatment date the indwelling Foley catheter change was due or last changed. On 09/15/22 at 9:33 a.m., Staff A stated recurring urinary catheter change due dates should have been documented in the POC for patient #5.

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 reviews and interview the agency failed to ensure: 1. SN performed indwelling Foley catheter change was ordered by the physician for one (Patient #14) of 17 patients and; 2. SN performed wound care was ordered by the physician for one (Patient #15) of 17 patients. Findings: Patient #14 A review of the plan of care dated 05/24/22 to 07/22/22 showed no orders for SN to perform indwelling Foley catheter change. Documentation showed SN performed indwelling Foley catheter change during the SN visit conducted on 06/03/22. On 09/15/22 at 9:55 a.m., Staff A stated SN should have obtained a physician’s order to change the indwelling Foley catheter for patient #14. Patient #15 A review of the plan of care dated 03/24/22 to 05/22/22 showed no orders for SN to perform wound site care, including application of tubagrip to bilateral lower extremities. Documentation showed SN performed wound site care and applied tubagrip to bilateral lower extremities during the SN visit conducted on 04/13/22. On 09/15/22 at 10:05 a.m., Staff A stated SN should have obtained a physician’s order to perform wound site care and apply tubagrip to bilateral lower extremities for patient #15.

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 and physician for one (Patient #9) of 17 patients. Findings: Patient #9 A review of a plan of care dated 08/05/22 to 10/13/22 documented a primary diagnosis of wound to right lower extremity and showed orders for SN to assess and perform wound site care: cleanse with saline, apply calcium alginate, and cover with dry sterile dressing to right lower extremity two times a week. Documentation showed no wound site assessment or wound care was conducted during SN visits dated 08/16/22, 08/18/22, 08/22/22 and on 08/25/22. Documentation of SN visits on 08/18/22, 08/22/22 and on 08/25/22 stated the wound site was healed. Documentation showed no physician notification or coordination of care to inform the wound site was healed and showed no change in orders. On 09/15/22 at 09:42 a.m., Staff A stated SN should have followed up with the physician to inform the wound site had healed and obtain additional orders for patient #9.

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: 1. Conduct PT visit frequency as ordered by the physician for three (Patients #4, 6 and #14) of 17 patients; 2. SN to conduct catheter treatment interventions as ordered for two (Patient #5 and #14) of 17 patients; 3. SN to conduct ankle circumference measuring interventions as ordered for one (Patient #9) of 17 patients; 4. SN to notify the physician of FSBS and pain levels outside of reporting parameters for one (Patient #10) of 17 patients; 5. SN to administer medications treatment interventions as ordered for one (Patient #13) of 17 patients and; 6. Conduct SN visit frequency as ordered by the physician for one (Patient #15) of 17 patients. Findings: Patient #4 A review of the POC dated 08/31/22 to 10/29/22 showed orders for a PT visit frequency of one time a week for one week, two times a week for four weeks, then one time week for one week. Documentation showed during week of 09/04/22 to 09/10/22, a PT visit was conducted on 09/07/22 (two visits ordered, one visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visit and no change in orders. On 09/15/22 at 09:30 a.m., Staff A stated PT staff should have conducted two visits during week of 09/04/22 to 09/10/22 for patient #4. Patient #5 A review of the POC dated 07/31/22 to 09/28/22 showed orders for SN to change suprapubic catheter every month. Documentation showed the catheter change was due during the SN visit conducted on 08/03/22. SN visit note dated 08/03/22 documented no catheter change was performed. On 09/15/22 at 09:33 a.m., Staff A stated SN staff should have changed the suprapubic catheter as ordered during the SN visit conducted on 08/03/22 for patient #5. Patient #6 A review of the POC dated 07/28/22 to 09/25/22 showed orders for a PT visit frequency of one time a week for one week, two times a week for three weeks, then one time week for four weeks. Documentation showed during week of 08/21/22 to 08/27/22, a PT visit was conducted on 08/26/22 (two visits ordered, one visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visit and no change in orders. On 09/15/22 at 09:35 a.m., Staff A stated PT staff should have conducted two visits during week of 08/21/22 to 08/27/22 for patient #6. Patient #9 A review of the POC dated 08/15/22 to 10/23/22 showed orders for a SN visit frequency of two time a week for nine weeks. Documentation showed SN to conduct ankle circumference monitoring and report increase of two centimeters to the physician. SN visit note dated 08/25/22 documented no ankle circumference measurements. Documentation showed no patient/caregiver refusal of ankle circumference measurements, no physician notification and no change in orders. On 09/15/22 at 9:42 a.m., Staff A stated there was no documentation which showed ankle circumference monitoring occurred during the SN visit on 08/25/22 for patient #9. Patient #10 A review of the POC dated 08/04/22 to 10/02/22 showed orders for a SN visit frequency of one time a week for one week, once a week every two weeks times for two weeks, then one time a week for five weeks and for SN to assess and instruct on disease management and report pain levels greater than six and blood sugar levels pulse rate greater than 180. SN visit dated 08/04/22 documented a BS level of 274. Documentation showed no physician notification of the BS level outside of reporting parameters and no change in orders. SN visit dated 08/25/22 documented a pain level of eight and documentation showed no physician notification of the pain level outside of reporting parameters and no change in orders. On 09/15/22 at 9:45 a.m., Staff A stated there was no physician notification of the pain level or blood sugar level outside of the reporting parameter on 08/04/22 and 08/25/22 for patient #10. Patient #13 A review of the POC dated 07/12/22 to 09/17/22 showed orders for SN to perform FSBS each visit and administer sliding scale insulin as ordered. SN visit note dated 07/25/22 documented a blood sugar level of 174, two units of Novolog insulin for BS 151-200 was ordered. Documentation showed no insulin was administered. SN visit note dated 08/02/22 documented a blood sugar level of 178, two units of Novolog insulin for BS 151-200 was ordered. Documentation showed no insulin was administered. On 09/15/22 at 09:50 a.m., Staff A stated SN staff should have administered the Novolog insulin as ordered during SN visits on 07/25/22 and 08/02/22 for patient #13. Patient #14 A review of the POC dated 05/24/22 to 07/22/22 showed orders for a PT visit frequency of two times a week for one week, one time a week for one week, two times a week for four weeks, then one time week for three weeks. Documentation showed during week of 06/12/22 to 06/18/22, a PT visit was missed on 06/16/22 (two visits ordered, no visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visit and no change in orders. Documentation showed during week of 07/10/22 to 07/16/22, a PT visit was missed on 07/13/22 (two visits ordered, no visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visit and no change in orders. On 09/15/22 at 09:55 a.m., Staff A stated PT staff should have conducted two visits during weeks of 06/12/22 to 06/18/22 and 07/10/22 to 07/16/22 for patient #4. Patient #15 A review of the POC dated 03/24/22 to 05/22/22 showed orders for a SN visit frequency of one time a week for eight weeks. Documentation showed during week of 04/03/22 to 04/09/22, a SN visit was missed on 04/07/22 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visit and no change in orders. Documentation showed during week of 04/10/22 to 04/16/22, a SN visit was missed on 04/12/22 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visit and no change in orders. On 09/15/22 at 10:15 a.m., Staff A stated SN staff should have conducted visits during weeks of 04/03/22 to 04/09/22 and 04/10/22 to 04/16/22 for patient #15.

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 four (Patients #3, 5, 13 and #14) of 17 patients. Findings: Patient #3 A review of the clinical record documented transfer from the agency on 09/04/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. Patient #5 A review of the clinical record documented transfer from the agency on 07/09/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. Patient #13 A review of the clinical record documented discharge from the agency on 08/17/22 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #14 A review of the clinical record documented transfer from the agency on 07/14/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. On 09/15/22 at 10:30 a.m., Staff A stated no transfer and/or discharge summaries were sent to the receiving service providers for patients #3, 5, 13 and #14.