Every finding on record at Indian Territory Home Health and Hospice II, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/09/24 to 04/11/24. 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 in conjunction with complaint (105617) at the agency on 04/09/24 to 04/11/24. An entrance conference was conducted with Staff B and by phone Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the re-certification survey. No deficiencies were cited related to the complaint. Glossary: Pts Patients POC Plan of Care SN Skilled Nurse/Nursing

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 review and interview, the agency failed to ensure: 1. SN notified the physician of a pain level outside the ordered parameters for one (Patient #1) of 19 patients; 2. SN frequencies were followed as ordered for two (Patient #2 and 14) of 19 patients. 1. Patient #1 A review of the POC dated 01/21/24 to 03/20/24 showed an order for the physician to be notified of pain greater than six out of ten. A review of a SN note dated 03/18/24 showed the patient’s reported pain as seven out of ten. Documents showed no physician notification for the reported pain greater than six. 2. Patient #2 A review of a POC dated 12/21/23 to 02/18/24 showed a SN frequency of once a week for eight weeks. A review of a SN missed visit note dated 01/17/24 documented the reason for the missed visit as patient not home, and no other visits documented for the week of 01/14/24 to 01/20/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #14 A review of the POC dated 01/22/24 to 03/21/24 showed a SN frequency of once a week for nine weeks. A review of a SN missed visit note dated 03/01/24 documented the reason for the missed visit as unavailable due to a lawyer’s appointment, and no other visits documented for the week of 02/25/24 to 03/02/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. On 04/11/24 at 1:27 p.m., Staff A stated: 1. there was no documentation of physician notification of the pain level being out of parameters for Patient #1; and 2. the SN frequencies for Patients #2 and 14 were not met as ordered by the physician.

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 accurate treatment information were contained in the clinical record for three (Patients #10, 11 and 18) of 19 patients. Patient #10 A review of the POC dated 02/11/24 to 04/10/24 showed an order for oxygen to be administered at 4 liters via nasal cannula continuous. A review of the medication administration record showed an order for oxygen at 2 liters continuous. Patient #11 A review of the POC dated 02/08/24 to 04/07/24 showed an order for oxygen to be administered at 2 liters via nasal cannula continuous. A review of the medication administration record showed an order for oxygen at 2 liters as needed. Patient #18 A review of the POC dated 03/26/24 to 05/24/24 showed an order for oxygen to be administered at 2 liters via nasal cannula at bedtime. A review of the medication administration record showed no oxygen ordered/listed. On 04/11/24 at 1:32 p.m., Staff A stated the oxygen order for Patients #10, 11 and 18 should have been clarified with the provider and entered correctly onto the medication administration record.

The Oklahoma State Department of Health conducted a follow-up Medicare Emergency Preparedness Program survey at the agency on 04/27 /21 - 04/29/21. 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 agency on 04/27/21 - 04/29/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff C was identified as the contact person for administrative issues and Staff A and B were identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff B and by telephone with Staff C. Deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: POC Plan of Care Pt Patient SN Skilled Nurse

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure frequencies were followed as ordered for one (Pt #16 and 17) of 17 patients. Findings: Pt #16 A review of a POC dated 12/16/20 - 02/13/21 showed orders for a SN frequency of three items a week for eight weeks and then once a week for one week. A review of clinical notes showed two SN visits the week of 12/20/20 - 02/13/21 (one missing). Documentation showed no orders for SN frequency changes, no patient/caregiver refusal and no missed visit notes. Pt #17 A review of the POC dated 12/10/20 to 02/07/21 showed aide visits ordered starting 12/10/2 of once a week for one week and then twice a week for two weeks. A review of the aide notesl showed no aide visits completed the week of 12/20/20 - 12/26/20 (one visit missing). Documentation showed no orders for aide frequency changes, no patient/caregiver refusal of visits and no missed visit notes. On 04/29/21 at 12:34 pm, Staff B stated there was no missed visit notes completed or SN frequency order change for Pt #16 and the ordered aide frequency was not followed for Pt #17.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure case conferences were conducted for one (Pt #13) of 17 patients. Findings: Pt #13 A review of records showed no case conference completed from 10/16/21 - 04/29/21. The most recent completed POC was dated 02/13/21 - 04/13/21. On 04/29/21 at 12:22 pm, Staff B stated no documented case conference was in the patient's clinical record.

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 communication and coordination with the physician for: 1) a pain level above parameters ordered in the POC for one (Pt #7) of 17 patients; and 2) a heart rate above parameters ordered in the POC for one (Pt #17) of 17 patients. Findings: Pt #7 A review of the POC dated 03/01/21 - 04/29/21 showed orders for licensed professional to report a pain level greater than 5. SN notes dated 03/17/21 and 04/13/21 showed a pain level rated an 8 out of 10 with no physician notification. Pt # 17 A review of the POC dated 12/10/20 - 02/07/21 showed orders for licensed professional to report a heart rate greater than 100. A SN note dated 12/21/20 showed a heart rate of 102 with no physician notification. On 04/29/21 at 12:20 pm, Staff B stated there was no documentation of a physician notification of elevated pain for Pt #7.

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 the accurate documentation of a clinical notes for one (Pt #2) of 17 patients. Findings: Pt #2 A review of the medical record showed a POC dated 01/23/21 - 03/23/21 with a primary diagnosis of pressure ulcer of sacral region, stage 3. SN notes dated 02/24/21, 02/26/21, 03/03/21, 03/05/21, 03,08,21, 03/10/21, 03/12/21, 03/15/21, 03/17/21, 03/19/21 and the comprehensive recert assessment 03/22/21 documented the wound was located on the patient's coccyx wound (not a sacral wound). On 04/29/21 at 11:20 am, Staff B stated the record for Pt #2 contains incorrect information.

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 budget, QAPI program and policies and procedures for all agency patients and employees during calendar year 2020. A review of administrative records for calendar year of 2020 showed no review and approval of: 1) annual budget; 2) comprehensive QAPI program and PIP/PIPS; 3) policy and procedures. Findings: On 04/2721 at 9:45 am the Surveyor requested the governing body minutes for 2019 and 2020. The surveyor was not provided governing body minutes for the calendar year 2020. On 04/29/21 at 10:00 the surveyor requested the governing body minutes for the calendar year of 2020. The request yielded no governing body documentation for 2020. On 04/29/21 at 12:35 pm, Staff B reported she was unable to provide the requested governing body minutes for 2020.