Every finding on record at Ideal Home Care, L.P.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 02/04/25 to 02/05/25. No deficiencies were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the hospice on 02/04/25 to 02/05/25. An entrance conference was conducted with Staff A. Staff B was identified as the contact person for administrative issues and Staff A was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. A standard level deficiency was cited as a result of the Medicare re-certification survey.

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 plan of Care to the Assisted Living Facility for one (Patient #9) of three patients residing in Assisted Living Facilities. Findings: Patient #9 A review of the assisted living center clinical record showed no plan of care was provided to the facility after a start of care dated 01/07/25. On 2/05/25 at 11:17 am Assisted Living Staff #1 stated there was no plan of care for Patient #9. On 2/05/25 at 12:50 pm Staff A stated if the patient is a new start of care, the plan of care should be provided to the facility within 5-7 days.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/25/22 to 03/29/22. 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 03/25/22 to 03/29/22. 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 clinical issues and Staff B was identified as the contact person for administrative issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: POC Plan of Care PT Physical Therapy SN Skilled Nurse

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a medication regimen change was updated on the medication profile for one (Patient #9) of 17 patients. Findings: Patient #9 A review of the plan of care dated 03/08/22 to 05/06/22 documented a principal diagnosis of sciatica. A PT coordination note dated 03/13/22 documented the patient had a new medication for pain. The documentation did not identify the medication. A review of the clinical record showed no update to the medication profile for the medication and showed no review for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy On 03/29/22 at 10:30 a.m., Staff B stated the medication in question was gabapentin and it should have been added to the medication profile for Patient #9 and reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy.

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 three (Patient’s #2, 6 and 12) of 17 patients. Findings: An agency policy titled, Pain Assessment/Management, stated the agency will establish a goal for pain relief, develop and implement a plan to achieve the goal and that pain will be treated as a vital sign to ensure that pain is measured and treated. The policy documentation failed to show a specific parameter level for the reporting of pain levels to the physician. An agency form titled, Vital Sign Report, showed an upper reporting parameter limit for pain of 5. Patient #2 A review of a plan of care dated 03/07/22 to 05/05/22 documented a diagnosis of Browns-Sequard syndrome and a secondary diagnosis of paraplegia. Documentation showed the POC documented PT to provide teaching to properly manage pain with a patient goal to verbalize/demonstrate ability to manage pain by the end of the episode but showed no physician reporting parameter of pain levels. Physical therapy note dated 03/15/22 showed a pain level of 5 of 10. Documentation showed no physician notification of the patient's pain level, no change in orders and no update to the POC. Patient #6 A review of a plan of care dated 02/18/22 to 04/18/22 documented a diagnosis of hemiplegia following cerebral infarct affecting right dominant side. Documentation showed the POC documented PT to provide teaching to properly manage pain with a patient goal to verbalize/demonstrate ability to manage pain but showed no physician reporting parameter of pain levels. Physical therapy notes dated 02/21/22 showed a pain level of 5 of 10 and on 02/28/22 showed a pain level of 5 of 10. Documentation showed no physician notification of the patient's pain levels, no change in orders and no update to the POC. Patient #12 A review of a plan of care dated 03/12/22 to 05/10/22 documented a diagnosis of venous insufficiency and a secondary diagnosis of non-pressure chronic ulcers to bilateral lower extremities. Documentation showed the POC documented SN to provide teaching to properly manage pain with patient goals to verbalize/demonstrate ability to manage pain and wound status will improve with a decrease in pain. The documentation showed no physician reporting parameter of pain levels and showed no physician notification of the patient's pain levels, no change in orders and no update to the POC. On 03/29/22 at 11:00 a.m., Staff A stated the POC’s for Patient’s #2, 6 and #12 did not include individualized pain reporting parameters related to the management of the patient's pain levels.

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 reviews and interview, the agency failed to ensure SN staff performed weekly wound care measurements and obtained patient weights every visit for one (Patient #12) of 17 patients. Findings: Patient #12 A review of the POC dated 03/12/22 to 05/10/22 showed a SN frequency of two times a week for eight weeks then one time a week for one week for and orders for SN to perform wound care to bilateral lower extremities and obtain patient weight each SN visit. Clinical documentation showed no wound care measurement were conducted during the SN visits to perform wound care on 03/15/22, 03/18/22, 03/22/22 and on 03/25/22; and no patient weights were obtained during the SN visits conducted on 03/15/22, 03/18/22 and on 03/25/22. Documentation showed no physician notification of change in wound status or patient’s weight, no change in orders, and no patient or caregiver refusal of the wound care measurements or weight. On 03/29/22 at10:35 a.m., Staff A stated wound care measurements should have been conducted by the SN at least weekly and the patient’s weight should have been conducted by the SN each visit for Patient #12.

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 transfer/discharge summary was provided to receiving service providers for one (Patient #13) of 17 patients. Findings: Patient #13 A review of the clinical record showed the patient was discharged from the agency on 01/10/22 to a hospice care service provider. Documentation showed no discharge summary provided to the hospice care service provider. On 03/29/22 at 10:40 a.m., Staff A stated no discharge summary was sent to the receiving hospice care service provider for Patient #13.