Every finding on record at Heritage Management Services L L C

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/13/25 to 01/15/25. 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 01/13/25 to 01/15/25. 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 Staff D for clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D and E. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: EMR Electronic Medical Record POC Plan of Care Pt/Pt's Patient/Patients SN Skilled Nursing

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 for one (Pt #5) of 17 patients. Findings: Pt #5 A review of the plan of care dated 12/13/24 to 02/10/25 documented a principal diagnosis of hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease. The POC showed orders for skilled nurse/therapist to assess patient/caregiver's knowledge of disease processes with emphasis on musculoskeletal system and integumentary systems. The POC showed no orders for skilled nurse/therapist to assess patient/caregiver's knowledge of disease processes with emphasis on the primary diagnosis and many secondary diagnoses of the cardiovascular and genitourinary systems. On 01/15/25 at 11:35 am, Staff D stated the POC for Pt #5 was not patient specific.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a caregiver was trained on the patient's wound care as ordered by the physician for one (Pt's #4) of 17. Findings: Patient #4 A review of the EMR showed a POC dated 12/13/24 to 02/10/25 with a physician ordered SN frequency of once a week for one week and three times a week for three weeks. The POC documented orders for SN to instruct patient/caregiver on wound care as follows to left heel: cleanse with sterile water and pat dry. Apply gauze impregnated with Medi honey to wound bed and cover with a hydrocolloid dressing then secure with transparent film. Change three times a week and prn and cover with a hydrocolloid dressing then secure with transparent film. The EMR showed missed visits 12/25/24 and 01/01/25 documenting: Patient's husband able to assist. A review of SN visits notes prior to these missed visits didn't document the patient's husband was educated on wound care and could competently show a return demonstration of the ordered wound care. On 01/15/25 at 11:30 a.m., Staff D stated SN documentation didn't show that the spouse was instructed and able to provide competent return demonstration of the wound care.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/21/22 to 03/22/22. 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 03/21/22 to 03/22/22. 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 issues and Staff B was identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C and D. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: PT Physical Therapy POC Plan of Care SN Skilled Nurse SOC Start of Care

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 pain reporting parameters for four (Patient’s #7, 14, 16, and #17) of 17 patients. Findings: Patient #7 A review of a plan of care dated 02/22/22 to 04/22/22 documented a diagnosis of right tibiae fracture and a secondary diagnosis of other chronic pain. Documentation showed orders for SN/PT to instruct and provide interventions to monitor and mitigate pain with a patient goal to report pain level’s less than 4 of 10 with daily activities by the time of discharge but showed no physician reporting parameter of pain levels. Physical therapy notes dated 02/25/22 showed a pain level of 6 of 10, 02/28/22 showed a pain level of 6 of 10, 03/01/22 showed a pain level of 6 of 10 and on 03/04/22 showed a pain level of 6 of 10. A SN note dated 03/16/22 showed a pain level of 6 of 10. Documentation showed no physician notification of the patient's pain levels and no change in orders. Patient #14 A review of a plan of care dated 02/26/22 to 04/26/22 documented a diagnosis of right knee joint replacement. Documentation showed orders for SN/PT to instruct and provide interventions to monitor and mitigate pain with a patient goal to report pain level’s less than 4 of 10 with daily activities by the time of discharge but showed no physician reporting parameter of pain levels. Physical therapy notes dated 03/04/22 showed a pain level of 6 of 10, 03/08/22 showed a pain level of 6 of 10, 03/09/22 showed a pain level of 6 of 10, 03/11/22 showed a pain level of 6 of 10, 03/14/22 showed a pain level of 6 of 10 , 03/16/22 showed a pain level of 6 of 10 and on 03/17/22 showed a pain level of 6 of 10. Documentation showed no physician notification of the patient's pain levels and no change in orders. Patient #16 A review of a plan of care dated 03/12/22 to 05/10/22 documented a diagnosis of pain due to broken right knee prosthesis and a secondary diagnosis of other chronic pain. Documentation showed orders for SN/PT to instruct and provide interventions to monitor and mitigate pain with a patient goal to report pain level’s less than 4 of 10 with daily activities by the time of discharge but showed no physician reporting parameter of pain levels. Physical therapy notes dated 03/12/22 showed a pain level of 6 of 10, 03/14/22 showed a pain level of 5 of 10, 03/16/22 showed a pain level of 6 of 10 and on 03/17/22 showed a pain level of 6 of 10. Documentation showed no physician notification of the patient's pain levels and no change in orders. Patient #17 A review of a plan of care dated 03/09/22 to 05/07/22 documented a diagnosis of right knee joint replacement. Documentation showed orders for SN/PT to instruct and provide interventions to monitor and mitigate pain with a patient goal to report pain level’s less than 4 of 10 with daily activities by the time of discharge but showed no physician reporting parameter of pain levels. Physical therapy notes dated 03/14/22 showed a pain level of 4 of 10, 03/18/22 showed a pain level of 5 of 10, 03/09/22 and on 03/21/22 showed a pain level of 4 of 10. Documentation showed no physician notification of the patient's pain levels and no change in orders. On 03/22/22 at 3:00 p.m., Staff B stated the POC’s for Patient’s #7, 14, 16, and #17 did not include pain reporting parameters related to the management of the patient's pain.

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 update the POC with verbal orders obtained from the physician for one (Patient #15) of 17 patients. Findings: Patient #15 A review of a POC dated 02/17/22 to 04/17/22 showed a SOC date of 02/17/22 and a principal diagnosis of aftercare following a joint replacement to the right knee. A skilled nurse evaluation dated 02/18/22 showed a SN visit frequency of one time a week for three weeks. Documentation showed the physician gave a verbal order for the SN visit frequency but showed no written documentation the verbal order was added as an update to the POC. A review of the clinical record showed a SN visit was conducted on 02/20/22, and a SN discharge occurred on 02/21/22. On 03/22/22 at 3:00 p.m., Staff B stated the SN should have documented the verbal order from the physician as an update to the POC.

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 completed discharge summaries were provided to receiving service providers for three (Patients #1, 2 and #5) of 17 patients. Findings: Patient #1 A review of the clinical record showed the patient was discharged from the agency on 01/14/22 to another home health care service provider. Documentation showed no discharge summary provided to the home health care service provider. Patient #2 A review of the clinical record showed the patient was transferred to in-patient hospital care services on 10/20/21 and discharged from the agency on 11/02/21 to in-patient hospital care services. Documentation showed no transfer or discharge summary provided to the hospital service provider. Patient #5 A review of the clinical record showed the patient was transferred to in-patient hospital care services on 01/12/22 and discharged from the agency on 02/06/22 to in-patient hospital care services. Documentation showed no transfer or discharge summary provided to the hospital service provider. On 03/22/22 at 3:30 p.m., Staff B stated no discharge summary was sent to: the receiving home health care service provider for Patient #1 and; the receiving hospital service providers for Patient #2 and #5.