Every finding on record at Healthcare Innovations/Travertine Health Services, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/29/23 to 03/30/23. 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 03/29/23 to 03/30/23. An entrance conference was conducted with Staff A, B and C. The survey process was explained. Questions were answered. Staff A and D were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, D, E, F, G, H and I. Standard level deficiencies were cited as a result of the survey. Glossary: FSBS Fingerstick blood sugar HHA Home Health Agency POC Plan of Care SN skilled nurse

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure recertification (updated comprehensive [OASIS]) assessments were completed for one (Patient #3) of seven patients. Findings: Patient #3 A review of the clinical record showed no documentation the patient had a recertification assessment between the dates of 12/04/22 to 12/07/22 (5 day recertification window) for recertification of HHA services for episode period of 12/08/22 to 02/06/23; and no subsequent recertification assessment between the dates of 02/02/23 to 02/06/23 (5 day recertification window) for recertification of HHA services for episode period of 02/07/23 to 04/07/23. Documentation showed no justification the recertification assessment was not completed, no patient or caregiver refusal of the recertification assessment, no physician notification of the missed recertification assessment and no changes in orders. On 03/29/23 at 1:35 p.m., Staff A stated the recertification had not been completed.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a discharge (updated [OASIS]) assessment was completed for two (Patients #3 and #6) of seven patients. Findings: Patient #3 A review of the clinical record showed: No documentation the patient was recertified for continued HHA services for episode period of 12/08/22 to 02/06/23; No subsequent recertification for HHA services for episode period of 02/07/23 to 04/07/23; No discharge assessment conducted. Documentation showed no justification why the discharge assessment was not completed, no patient or caregiver refusal of the discharge assessment, no physician notification of the missed discharge assessment and no changes in orders. On 03/29/23 at 1:35 p.m., Staff A stated the discharge (updated [OASIS]) assessments had not been completed. Patient #6 A review of the clinical record showed the patient was transferred without discharge from agency services to inpatient hospital provider services on 11/02/22. Documentation showed a physician’s order dated 11/10/22 to discharge the patient from HHA services. Documentation showed no discharge assessment conducted on 11/10/22; and a desk discharge (agency discharge without a visit) conducted on 01/12/23 (63 days after the discharge was ordered). Documentation showed no justification why the discharge OASIS assessment was not completed, no physician notification the patient was not discharge from the HHA until 01/12/23 and no changes in orders. On 03/29/23 at 1:50 p.m., Staff A stated the discharge (updated [OASIS]) assessment had not been completed when it was ordered by the physician on 11/10/22.

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 #1) of seven patients. Findings: Patient #1 A review of a plan of care dated 03/05/23 to 05/03/23 documented a primary diagnosis of Diabetes Mellitus Type II and showed orders for: SN visit frequency of twelve times week for one week, fourteen times a week for seven weeks, then eight times a week for one week and for SN to assess/perform FSBS and administer subcutaneous insulin medication two times a day and report to physician FSBS greater than 180. A review of clinical documentation showed auto-fax communications of FSBS levels outside of reporting parameters but showed no follow up physician coordination of care communications for continued elevated FSBS readings during: SN visits conducted on 03/17/23 for FSBS reading of 200; 03/18/23 FSBS reading of 218. 03/23/23 FSBS reading of 228, 03/25/23 FSBS reading of 242, 03/26/23 FSBS reading of AM 243 & PM 240, 03/27/23 FSBS reading of AM 186 & PM 206, 03/29/23 FSBS reading of 199. Documentation showed no physician follow up coordination of care communications to confirm notification of FSBS levels outside of reporting parameters and no changes in orders. On 03/29/23 at 1:20 p.m., Staff A the clinical record showed no physician follow up coordination of care communications to confirm notification of continued FSBS levels outside of reporting parameters.

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 patient discharge from HHA services as ordered by the physician for one (Patient #6) of seven patients. Findings: Patient #6 A review of the clinical record showed a physician’s order dated 11/10/22 to discharge the patient from HHA services. Documentation showed a desk discharge (agency discharge without a visit) was conducted on 01/12/23 (63 days after the discharge was ordered). Documentation showed no justification the discharge was not conducted when ordered, no patient/caregiver refusal of discharge, no physician notification the patient was not discharge from the HHA until 01/12/23 and no changes in orders. On 03/29/23 at 1:50 p.m., Staff A stated the discharge had not been conducted when it was ordered by the physician on 11/10/22.

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 #4 and #5) of seven patients. Findings: An agency policy titled Clinical records stated staff documents all direct care delivery during the visit. Patient #4 A plan of care dated 03/15/23 to 05/13/23 documented a principal diagnosis of chronic venous hypertension with ulcer to the lower extremity. Documentation showed a SN visit frequency of two times a week for one week, then three times a week for nine weeks. Documentation showed no SN visits notes for SN visits scheduled on 03/15/23, 03/17/23, 03/20/23, 03/22/23 and on 03/24/23 were completed and authenticated by the SN. On 03/29/23 at 1:40 p.m., Staff A stated visit notes for SN visits scheduled on 03/15/23, 03/17/23, 03/20/23, 03/22/23 and on 03/24/23 were not completed and authenticated by the SN. Patient #5 A plan of care dated 03/07/23 to 05/05/23 documented a principal diagnosis of pressure ulcer of the sacral region. Documentation showed a SN visit frequency of one time a week for four weeks, then one times every two weeks for two weeks. Documentation showed SN visit scheduled on 03/06/23 were later completed and authenticated by the SN on 03/16/23 and SN visit scheduled on 03/13/23 were later completed and authenticated by the SN on 03/16/23. On 03/29/23 at 1:45 p.m., Staff A stated visit notes for SN visits scheduled on 03/06/23 and on 03/13/23 were not completed and authenticated by the SN when direct care delivery was conducted during the visit.