Every finding on record at Integris Baptist Medical Center, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/21/22 to 06/23/22. 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 in conjunction with a Medicare complaint (complaint #61376) at the agency on 06/21/22 to 06/23/22. 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 and clinical 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. No deficiencies were cited related to the complaint Glossary: ADL Activities of Daily Living CHHA Certified Home Health Aide HHA Home Health Agency OT Occupational Therapy POC Plan of Care

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. Patient education on potential health outcomes related to refusal of OT visits for one (Patient #13) of 17 patients and; 2. Physician notification of the patient's continued refusal of OT visits for one (Patient #13) of 17 patients. Findings: Patient #13 A review of a plan of care for 05/03/22 to 07/01/22 showed an OT visit frequency of one day one, then two times a week for one week and three times a week for three weeks. A review of visit notes showed missed OT visits on 05/13/21 and 05/16/22 with a subsequent OT discipline discharge from agency services on 05/18/22. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of OT visits and no documentation to the physician of the patient's continued refusal of OT visits or discharge from the agency for non-compliance prior to the discharge date of 05/18/22. On 06/23/22 at 10:00 a.m., Staff A stated there was no documentation of: 1. Attempts to educate the patient of potential health outcomes related to refusal of OT visits and; 2. No physician notification of the patient's refusal of OT visits with subsequent discharge from the agency for non-compliance.

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 plan of care included pain reporting parameters for five (Patients #4, 5, 7, 8 and #10) of 17 patients. Findings: Patient #4 A review of the plan of care dated 04/02/22 to 05/31/22 documented a principal diagnosis of chronic kidney disease with heart failure. Documentation showed SN to assess and teach pain management techniques and pain scale with a patient goal of pain maintained by verbal or non-verbal means. Documentation showed no identification of pain level associated with pain maintained by verbal or non-verbal means and no pain reporting parameter for physician notification of the patient’s pain level outside of pain maintained by verbal or non-verbal means. Patient #5 A review of the plan of care dated 05/12/22 to 07/10/22 documented a principal diagnosis of acute pain due to trauma. Documentation showed SN to assess and teach pain management techniques and pain scale with a patient goal of pain maintained by verbal or non-verbal means. Documentation showed no identification of pain level associated with pain maintained by verbal or non-verbal means and no pain reporting parameter for physician notification of the patient’s pain level outside of pain maintained by verbal or non-verbal means. Patient #7 A review of the plan of care dated 04/03/22 to 06/01/22 documented a principal diagnosis of stage 3 pressure ulcer of the sacrum. Documentation showed SN to assess and teach pain management techniques and pain scale with a patient goal of pain maintained by verbal or non-verbal means. Documentation showed no identification of pain level associated with pain maintained by verbal or non-verbal means and no pain reporting parameter for physician notification of the patient’s pain level outside of pain maintained by verbal or non-verbal means. Patient #8 A review of the plan of care dated 04/22/22 to 06/20/22 documented a principal diagnosis of paraplegia. Documentation showed SN to assess and teach pain management techniques and pain scale with a patient goal of pain maintained by verbal or non-verbal means. Documentation showed no identification of pain level associated with pain maintained by verbal or non-verbal means and no pain reporting parameter for physician notification of the patient’s pain level outside of pain maintained by verbal or non-verbal means. Patient #10 A review of the plan of care dated 05/19/22 to 07/17/22 documented a principal diagnosis of acute respiratory failure. Documentation showed SN to assess and teach pain management techniques and pain scale with a patient goal of pain maintained by verbal or non-verbal means. Documentation showed no identification of pain level associated with pain maintained by verbal or non-verbal means and no pain reporting parameter for physician notification of the patient’s pain level outside of pain maintained by verbal or non-verbal means. On 06/23/22 at 10:50 a.m., Staff A stated individualized POCs should have documented pain reporting parameters for Patients #4, 5, 7, 8 and #10.

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 reviews and interview, the agency failed to ensure: SN performed wound care as ordered by the physician for one (Patients #3) of 17 patients and;CHHA visits were conducted as ordered by the physician for one (Patient #15) of 17 patients. Findings: Patient #3 A review of the POC dated 05/14/22 to 07/12/22 showed a SN visit frequency of one time a week for three weeks, then one time every other week for seven weeks to assess wound site to the right lower extremity and conduct wound care every visit. Documentation showed on 06/06/22 SN visit, SN applied a silver alginate dressing over the wound site (not ordered by the physician) and on 06/16/22 SN visit, SN applied a Plurogel dressing over the wound site (not ordered by the physician). Documentation showed no physician notification of change in wound status, no change in orders, and no patient or caregiver refusal of the ordered wound care to the right lower extremity. On 06/23/22 at 10:20 a.m., Staff A stated the SN should have performed wound care as ordered by the physician for Patient #3. Patient #15 A review of the POC dated 05/13/22 to 07/11/22 showed a CHHA visit frequency of two times a week for two weeks to assist patient with bathing and related ADLs. Documentation showed the patient was discharged from agency services on 06/01/22. During the week of 05/29/22 to 06/04/22 CHHA visits were conducted on 05/31/22 and on 06/03/22 (two visits conducted, one visit conducted after the patient discharged from agency services). Documentation showed no physician notification of the CHHA visit after the patient discharged from agency services. On 06/23/22 at 11:00 a.m., Staff A stated the CHHA should not have conducted the visit on Patient #15 after the patient was discharged from agency services.

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 care was coordinated between the agency and physician for one (Patient #3) of 17 patients. Findings: Patient #3 A review of the POC dated 05/14/22 to 07/12/22 documented a primary diagnosis of unstageable pressure ulcer right lower extremity and showed a SN visit frequency of one time a week for three weeks, then one time every other week for seven weeks. Documentation showed a case communication note from the hospital system transition care team to the HHA dated 06/06/22 stated during a follow up telephone call to the patient; the patient was tearful and crying, reported she had been unable to get out of bed for 2-3 days and her lower extremities were very swollen. A communication note dated 06/10/22 documented a missed SN visit (one visit ordered, one visit missed). Documentation showed no physician notification to reported changes in the patient’s status on 06/06/22, no notification of the missed SN visit on 06/10/22, and no changes in orders. On 06/23/22 at 10:15 a.m., Staff A stated the physician should have been notified of reported changes in the patient’s status on 06/06/22 and of the missed SN visit on 06/10/22 for patient #3.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 331 patients and all employees. Findings: A review of administrative records showed no data collection activities utilized in the agency's QAPI program for calendar years 2020, 2021 and 01/01/22 through 06/23/22. On 06/23/22 at 11:00 a.m., Staff A stated the agency had no documentation which showed analysis of data collected through the QAPI program and no program improvement data that showed improved quality of patient care for calendar years 2020, 2021 and 01/01/22 through 06/23/22.

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 331 patients and all employees. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar years 2020, 2021 and 01/01/22 through 06/23/22. On 06/23/22 at 11:00 a.m., Staff A stated they had no QAPI documentation which showed QAPI program activities for calendar years 2020, 2021 and 01/01/22 through 06/23/22.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Infection Control Program was included in QAPI activities for 331 patients and all employees. Findings: A review of QAPI administrative records showed no documentation of infection control surveillance data for calendar year's 2020, 2021 and 01/01/22 to 06/23/22. On 06/23/22 at 11:00 a.m., Staff A stated infection surveillance activities were not reported through the agency's QAPI program for calendar year's 2020, 2021 and 01/01/22 to 06/23/22.

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 on the POC for: 1. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for two (Patient #4 and #10) of 17 patients and; 2. SN to conduct assessment of patient pain every visit and notify the physician of reported pain levels greater than 7/10 for one (Patient #6) of 17 patients. Findings: Patient #4 A review of the POC dated 04/02/22 to 05/31/22 showed orders for SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight of two pounds in 24 hours or three to five pounds in a week. A review of clinical documentation showed no patient weight assessment conducted during SN visits on 04/08/22, 04/13/22, 04/26/22, 05/02/22, 05/10/22, 05/12/22 and 05/17/22. Documentation showed no patient/caregiver refusal of patient weight assessment, no physician notification and no change in orders. Patient #6 A review of the POC dated 05/19/22 to 07/17/22 showed orders for SN to conduct assessment of patient pain every visit and notify physician for patient reported pain level greater than 7/10. A SN visit note dated 06/04/22 showed documentation the patient reported pain as severe, 8/10. Documentation showed no physician notification of the patient’s reported pain level and no changes in orders. Patient #10 A review of the POC dated 05/19/22 to 07/17/22 showed orders for SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight of two pounds in 24 hours or three to five pounds in a week. A review of clinical documentation showed no patient weight assessment conducted during SN visits on 06/06/22 and 06/15/22. Documentation showed no patient/caregiver refusal of patient weight assessment, no physician notification and no change in orders. On 06/23/22 at 10:15 a.m., Staff A stated: SN should have conducted patient weight assessments for Patient #4 and #10 every SN visit and;The physician should have been notified of the reported pain level 8/10 for patient #6.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for one (Patients #2) of 17 patients. Findings: Patient #2 A plan of care dated 05/03/22 to 07/01/22 showed a CHHA visit frequency of once a week for eight weeks. A review of the clinical record showed CHHA visits conducted on 05/13/22, 05/21/22, 05/27/22, 06/03/22, 06/10/22 and on 06/17/22 with supervisory visits completed on 05/02/22 and on 05/23/22 (21 days between supervisory visits). Documentation showed no patient/caregiver refusal of the supervisory visit, physician notification or change in orders. On 06/23/22 at 10:00 a.m., Staff A stated the CHHA supervisory visits for Patient #2 should have been completed every 14 days.

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 one (Patients #14) of 17 patients. Findings: Patient #14 A review of the clinical record documented discharge from the agency to other in-patient provider services on 05/20/22. Documentation showed no discharge summary was provided to the other in-patient service provider. On 06/23/22 at 11:00 a.m., Staff A stated no discharge summary was sent to the receiving in-patient service providers for Patient #14.