Every finding on record at Innovative Senior Care of Home Health of Tulsa, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 12/29/25 to 12/30/25. A deficiency was cited as a result of the Emergency Preparedness Program survey.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure collaboration with local, tribal, regional, State, and Federal emergency preparedness officials for all patients and employees. A request for documentation of collaboration with local, tribal, regional, State, and Federal emergency preparedness officials yielded no results. On 12/30/25 at 1:54 pm Staff B stated there was no documentation of emergency preparedness collaboration with others.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 12/29/25 - 12/30/25. An entrance conference was conducted with Staff A. the survey process was explained. Questions were answered. Staff B 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 A and B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: Pt - Patient

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 an elevated pain level was reported to the physician in a timely manner for one (Pt #4) of 13 patients. Findings: Pt #4 A review of a plan of care dated 12/06/25 - 02/03/26 showed orders to notify the physician of a pain level above 6. The start of care assessment dated 12/06/25 showed a pain level of 8, Documentation showed no physician notification until 12/28/25. On 12/30/25 at 3:39 pm, Staff A stated the physician was not made aware of the pain level of 8 until 12/28/25.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nursing frequency was followed as ordered by the physician for one (Pt #9) of 13 patients. Findings: Pt #9 A plan of care dated 12/20/258 - 02/17/25 showed orders for skilled nursing visit frequency of one week one, then three week one. A review of SN visit notes showed during the week of 2/21/25 - 12/27/25 one visit conducted (three visits ordered). The clinical record showed no refusal by the patient or caregiver, no request for frequency clarification, and no physician order to change skilled nursing visit frequencies. On 12/30/25 at 3:51 pm, Staff A stated the skilled nurse visit frequency was not followed for the week of 12/21/25 -12/27/25.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/26/22 to 10/27/22. 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 10/26/22 to 10/27/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff B, C, D, E, F and G. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: ABN advance beneficiary notice QAPI Quality Assessment Performance Improvement

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 for one (Patient #8) of 10 patients. Findings: Patient #8 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency for no Face to Face requirement on 10/20/22. On 10/27/22 at 11:15 a.m., Staff B stated: 1. There was no ABN notice in the clinical records for Patients #8 and; 2. Patient #8 should have received an ABN notice prior to being discharged from the agency.

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 completed for two (Patients #1 and #2) of 10 patients. Findings: Patient #1 A review of the clinical record documented a referral date of 09/22/22 to the agency and showed an initial visit/start of care assessment was conducted on 09/25/22. Documentation showed no patient/caregiver refusal of an initial visit assessment, no physician notification and no changes in orders. On 10/27/22 at 10:55 a.m., Staff B stated the agency did not conduct an initial assessment visit within 48 hours of referral for patient #1. Patient #2 A review of the clinical record documented a referral date of 05/27/22 to the agency and showed an initial visit/start of care assessment was conducted on 05/31/22. Documentation showed no patient/caregiver refusal of an initial visit assessment, no physician notification and no changes in orders. On 10/27/22 at 11:00 a.m., Staff B stated the agency did not conduct an initial assessment visit within 48 hours of referral for patient #2.

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 recurring urinary catheter change treatment due dates were documented for two (Patients #1 and #5) of 10 patients. Findings: Patient #1 A review of the plan of care dated 09/25/22 to 11/23/22 documented a principal diagnosis of benign prostatic hyperplasia with urinary tract symptoms and orders for SN to change suprapubic catheter every 30 days. POC documentation showed no treatment date the suprapubic catheter change was due or last completed. Patient #5 A review of the plan of care dated 07/25/22 to 09/22/22 documented a principal diagnosis of multiple sclerosis and POC showed orders for SN to manage and change indwelling Foley catheter every month. POC documentation showed no treatment date the indwelling Foley catheter change was due or last completed. On 10/27/22 at 11:00 a.m., Staff B stated recurring urinary catheter change due dates and/or last change dates should have been documented for in the POC’s for patients #1 and #5.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees. Findings: A review of administrative records showed no documentation of ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar year 2021. On 10/27/22 at 10:00 a.m., Staff B stated they had no QAPI documentation which showed QAPI program activities for calendar year 2021.

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. SN to notify the physician of patient refusal of suprapubic urinary catheter change treatment intervention for one (Patient #1) of 10 patients and; 2. Conduct SN visit frequency as ordered by the physician for one (Patients #7) of 10 patients. Findings: Patient #1 A review of the POC dated 09/25/22 to 11/23/22 showed orders for a SN visit frequency of two times a week for one week, then one time a week for seven weeks. Documentation showed during weeks of 10/16/22 to 10/22/22, a SN visit was conducted on 10/21/22. Documentation showed the patient refused suprapubic urinary catheter change treatment intervention. Documentation showed no physician notification of patient refusal of recurring suprapubic urinary catheter change treatment intervention and no change in orders. On 10/27/22 at 10:55 a.m., Staff B stated there was no physician notification of patient refusal of recurring suprapubic urinary catheter change treatment intervention. Patient #7 A review of the POC dated 09/10/22 to 11/08/22 showed orders for a SN visit frequency of one time a week for one week, one time a week for eight weeks, then one time a week for one week and for SN to perform wound site assessment and care to the right foot. Documentation showed during week of 09/25/22 to 10/01/22, a SN visit was scheduled for 09/27/22 and missed. A second SN visit was conducted on 09/29/22 (two visits ordered, one visit missed). Documentation showed no attempt to reschedule the first visit during the same week, no physician notification of missed visit and no change in orders. Documentation showed during week of 10/09/22 to 10/15/22, a SN visits were scheduled for 10/13/22 and 10/14/22 and missed (two visits ordered, two visits missed). Documentation showed no patient/caregiver refusal of visits, no attempt to reschedule either visit during the same week, no physician notification of missed visits and no change in orders. On 10/27/22 at 11:12 a.m., Staff B stated SN did not conduct the visit frequency as ordered on the POC.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative records showed no documentation of ongoing QAPI program activities which included multi-disciplined skilled professional staff participation for calendar years 2020 and 2021. On 10/27/22 at 10:00 a.m., Staff B stated the agency showed no QAPI program activities with multi-disciplined skilled professional staff participation for calendar years 2020 and 2021.

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 discharge summary was provided for three (Patients #8, 9 and #10) of 10 patients. Findings: Patient #8 A review of the clinical record documented discharge from the agency on 10/20/22 to assisted living provider services. Documentation showed no discharge summary was provided to the assisted living service provider. Patient #9 A review of the clinical record documented discharge from the agency on 09/11/22 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #10 A review of the clinical record documented discharge from the agency on 09/22/22 to in-patient hospital provider services. Documentation showed no discharge summary was provided to the in-patient hospital service provider. On 10/27/22 at 11:15 a.m., Staff B stated no discharge summary was sent to the receiving service providers for patients #8, 9 and #10.