Every finding on record at Interim Healthcare, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/12/23 to 12/14/23. 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 investigations for complaint #99606 and #101986 at the agency on 12/12/23 to 12/14/23. An entrance conference was conducted with Staff A, B, C, D and E. 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 person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D and E. Standard level deficiencies unrelated to complaint allegations were cited as a result of the survey, Glossary: CHHA certified home health aide HHA Home Health Agency OT Occupational Therapy PT Physical Therapy POC Plan of Care SN skilled nurse ST Speech therapy

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator’s name and contact information for agency complaints was a part of the admission packet for all patients. Findings: Review of administrative records (start of care patient information packet/booklet) showed no agency administrator’s name and contact information related to complaint and grievance procedures for the agency. Patient #11 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #12 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #13 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #14 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #15 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. On 12/14/23 at 10:30 a.m., Staff A reviewed the start of care patient information packet/booklet and stated the administrator’s name and contact information was not in the packet/booklet information given to the patients at the time of admission to the agency.

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 advance beneficiary notice and/or HHCOC notice prior to discharge from agency services were provided to two (Patients #3 and 5) of 17 patients. Findings: Patient #3 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 06/09/23. On 12/13/23 at 12:20 p.m., Staff A stated there was no ABN or HHCOC notices in the clinical record for patient #3 prior to being discharged from the agency for no continued physician oversite. Patient #5 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 11/15/23 for denial of payment by insurance source/payer. On 12/13/23 at 12:30 p.m., Staff A stated there was no ABN or HHCOC notices in the clinical record for patient #5 prior to being discharged from the agency for denial of payment by insurance source/payer.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a discharge oasis was completed by the agency for one (Patient #10) of 17 patients. Findings: Patient #10 A review of the clinical record showed a start of care date of 03/06/23. Documentation showed a physical therapy discipline discharge occurred on 04/03/23, an occupational therapy discipline discharged occurred on 04/05/23 and a missed visit by a registered nurse occurred on 04/14/23. Documentation showed no other visit occurred after 04/05/23 and showed no discharge from agency services, no discharge OASIS assessment conducted and no physician notification. On 12/13/23 at 12:50 p.m., Staff A stated no agency discharge and a discharge OASIS was completed on Patient #10.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a transfer/discharge summary for two (Patients #2 and #9) of 17 patients. Findings: Patient #2 A review of the clinical record showed the patient was discharged from the agency on 09/20/22. Documentation showed no discharge summary. Patient #9 A review of the clinical record showed the patient was transferred to in-patient hospital care and subsequently discharged from the agency on 12/09/23. Documentation showed no transfer summary, no in-patient follow up communication and no discharge summary. On 12/13/23 between 12:05 p.m. and 12:45 p.m., Staff A stated patients #2 and #9 did not have discharge summaries completed.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician follow up communication of care for missed and/or patient refusal of skilled nursing visits for one (Patient #6) of 17 patients. Findings: Patient #6 A review of the plan of care dated 07/27/23 to 09/24/23 showed orders for SN visit frequency of two times a week for three weeks, then one time a week for five weeks. Documentation showed SN missed visits on 08/04/23, 08/08/23, 08/11/23, 08/25/23, 08/26/23 and on 08/31/23 and showed a transfer with subsequent discharge to in-patient hospital services on 09/15/23. Documentation showed no follow up communication of care with the physician for missed/patient refusal of care SN visits and showed no changes in orders. On 12/13/23 at 12:35 p.m., Staff A stated there was no follow up communication of care to the physician for missed and/or patient refusal of skilled nursing visits.

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 physician orders were a part of the patients’ plans of care for: 1. SN to administer daily medications and perform SN interventions to change continuous glucose monitoring device sensors for three (Patients #12, 13 and #16) of 17 patients and; 2. SN wound site care and use of wound dressing materials for one (Patient #15) of 17 patients. Findings: Patient #12 A review of the POC dated 11/10/23 to 01/08/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. POC medication profile documented Dexcon (continuous glucose monitor) device sensor change every 10 days and Lantus 100 units/ml subcutaneous injection 25 units daily. Documentation showed no orders for SN to administer the Lantus daily or change the Dexcom sensor every 10 days. Documentation showed SN visits were conducted daily from 11/07/23 to 12/11/23 (35 visits through date of the POC review) for SN to administer the Lantus daily. A coordination of care note dated 11/22/23 showed the Lantus dose was decreased to 22 units daily. Documentation showed no physician notification of SN administering Lantus daily and no changes in orders. On 12/13/23 at 1:10 p.m., Staff A stated the POC for patient #12 did not contain physician orders for the SN to administer the injection of Lantus or to change the Dexcom device every 10 days. Patient #13 A review of the POC dated 11/10/23 to 01/08/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. POC medication profile documented Dexcon (continuous glucose monitor) device sensor change every 10 days and Basaglar 100 units/ml subcutaneous injection 6 units twice daily. Documentation showed no orders for SN to administer the Basaglar twice daily or change the Dexcom sensor every 10 days. Documentation showed SN visits were conducted daily from 11/10/23 to 12/11/23 (32 visits through date of the POC review) for SN to administer the Basaglar daily. Coordination of care notes dated 11/24/23 showed the Basaglar dose was decreased to 4 units twice daily and on 11/29/23 showed the Basaglar dose was changed to 8 units daily. Documentation showed no physician notification of SN administering Basaglar daily and no changes in orders. On 12/13/23 at 1:15 p.m., Staff A stated the POC for patient #13 did not contain physician orders for the SN to administer the injection of Basaglar or to change the Dexcom device every 10 days. Patient #15 A review of the POC dated 11/16/23 to 01/14/23 showed a SN visit frequency of one time a week for one week, then two times a week for eight weeks for SN to perform wound site care to left lower extremity for two times weekly dressing of choice (no identified wound site cleanser or dressing materials) and tubigrip. Documentation showed during SN visits conducted on 11/20/23, 11/24/23, 11/27/23, 11/30/23, 12/04/23 and on 12/07/23 no type of wound site cleansing solutions or dressing materials were documented. Documentation showed no physician notification and no changes in orders. On 12/13/23 at 1:25 p.m., Staff A stated the POC for patient #15 did not contain physician orders that identified wound site cleansers or dressing materials for wound care to the left lower extremity. Patient #16 A review of the POC dated 12/06/23 to 02/03/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. POC medication profile showed Glargine (insulin) 38 units subcutaneous injection daily and Trulicity 0.5 milliliters subcutaneous injection weekly. Documentation showed no orders for SN to administer the Glargine daily or Trulicity weekly. Documentation showed SN visits were conducted daily from 12/06/23 to 12/08/23 (3 visits through date of the POC review) for SN to administer the Glargine daily or Trulicity weekly. Documentation showed no physician notification of SN administering Glargine daily or Trulicity weekly and no changes in orders. On 12/13/23 at 1:35 p.m., Staff A stated the POC for patient #16 did not contain physician orders for the SN to administer the injections of Glargine daily or Trulicity weekly.

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. Physician ordered wound care dressing materials for one (Patient #7) of 17 patients; 2. Physician ordered MSW consult for one (Patient #9) of 17 patients and; 3. Physician ordered SN for indwelling urinary catheter treatment interventions for one (Patient #11) of 17 patients. Findings: Patient #7 A review of the POC dated 07/14/23 to 09/11/23 showed orders for SN to instruct caregiver to wash wound site to scrotum (wound site #2) with soap and water, apply Pleuragel and cover with Drawtex bandage daily. POC documentation showed no SN visit frequency and showed no SN goals related to wound site care/management. Documentation showed SN visits were conducted 07/17/23, 07/19/23 and 07/21/23 using Ca Alginate dressing materials during SN performed wound site care (no order). Documentation showed no physician notification and no changes in orders. On 12/13/23 at 12:40 p.m., Staff A stated the POC for patient #7 had no physician ordered: 1. SN visit frequency for wound care and management and; 2. Wound care orders did not include Ca Alginate dressing materials. Patient #9 A review of the POC dated 10/13/23 to 12/11/23 showed no orders for MSW consult. Documentation showed an MSW consult dated 10/16/23 was conducted. Documentation showed no physician notification and no changes in orders. On 12/13/23 at 12:45 p.m., Staff A stated the POC for patient #9 had no physician order for MSW consult. Patient #11 A review of the POC dated 10/28/23 to 12/26/23 showed orders for SN to perform monthly urinary catheter changes. POC documentation showed no urinary catheter treatment interventions, catheter size, last changed or change due date. SN visits conducted on 11/05/23 documented SN flushed the indwelling urinary catheter (no orders), 11/13/23 SN discontinued the indwelling urinary Foley catheter (no orders) and on 11/20/23 SN inserted a 16 French/15 milliliter urinary catheter (no orders). Documentation showed no physician notifications and no change in orders. On 12/13/23 at 1:05 p.m., Staff A stated the POC for patient #11 had no physician orders for urinary catheter treatment interventions, including orders to flush, discontinue or reinsert the urinary catheter.

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: 1. Coordination of care with the physician after physical therapy evaluation to establish a treatment plan and visit frequency for five (Patients #2, 4, 5, 7 and #11) of 17 patients; 2. Coordination of care with the physician after occupational therapy evaluation to establish a treatment plan and visit frequency for five (Patients #2, 4, 5, 6 and #7) of 17 patients and; 3. Coordination of care with the physician after speech therapy evaluation to establish a treatment plan and visit frequency for one (Patient #2) of 17 patients. Findings: Patient #2 A review of the POC dated 08/05/23 to 10/03/23 showed orders for PT evaluation (one time a week for one week, 08/05/23 to 08/10/23), OT evaluation (one time a week for one week, 08/05/23 to 08/10/23) and ST evaluation (one time a week for one week, 08/05/23 to 08/10/23). A PT evaluation dated 08/14/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed PT visits were conducted 08/24/23, 08/29/23 and on 09/07/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 08/16/23 showed a recommended OT visit frequency of one time a week for one week, two times a week for two weeks. Documentation showed OT visits were conducted on 08/23/23 and on 08/25/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. A speech therapy evaluation dated 08/25/23 showed a recommended ST visit frequency of one time a week for five weeks. Documentation showed ST visits were conducted on 08/25/23. Documentation showed no physician notification of the ST evaluation, ST visit frequency recommendation or change in physician orders. On 12/13/23 at 12:10 p.m., Staff A stated PT, OT and ST should have contacted the physician and documented coordination of care and a verbal order for the PT, OT and ST treatment plan and visit frequencies. Patient #4 A review of the POC dated 09/10/23 to 11/08/23 showed orders for PT evaluation (one time a week for one week, 09/10/23 to 09/16/23) and OT evaluation (one time a week for one week, 09/10/23 to 09/16/23). A PT evaluation dated 09/15/23 showed a recommended PT visit frequency of one time a week for one week, two times a week for two weeks, then one time a week for one week. Documentation showed PT visits were conducted 09/20/23, 09/22/23, 09/28/23, 09/29/23 and on 10/02/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 09/12/23 showed a recommended OT visit frequency of one time a week for one week, two times a week for three weeks. Documentation showed OT visits were conducted on 09/16/23, 09/22/23, 09/25/23 and on 09/28/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:22 p.m., Staff A stated PT and OT should have contacted the physician and documented coordination of care and a verbal order for the PT and OT treatment plan and visit frequencies. Patient #5 A review of the POC dated 10/24/23 to 12/22/23 showed orders for PT evaluation (one time a week for one week, 10/24/23 to 10/28/23) and OT evaluation (one time a week for one week, 10/24/23 to 10/28/23). A PT evaluation dated 10/25/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed PT visits were conducted 10/30/23, 11/01/23, 11/06/23 and on 11/08/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 10/25/23 showed a recommended OT visit frequency of one time a week for one week, then two times a week for two weeks. Documentation showed OT visits were conducted on 11/01/23, 11/02/23, 11/06/23 and on 11/14/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:30 p.m., Staff A stated PT and OT should have contacted the physician and documented coordination of care and a verbal order for the PT and OT treatment plan and visit frequencies. Patient #6 A review of the POC dated 07/27/23 to 09/24/23 showed orders for ST evaluation (one time a week for one week, 07/27/23 to 07/29/23) and OT evaluation (one time a week for one week, 07/27/23 to 07/29/23). A ST evaluation dated 08/09/23 showed a recommended ST visit frequency of one time a week for five weeks. Documentation showed ST visits were conducted 08/17/23. Documentation showed no physician notification of the ST evaluation, ST visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 08/09/23 showed a recommended OT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed OT visits were conducted on 08/11/23, 08/14/23, 08/18/23 and on 08/23/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:35 p.m., Staff A stated ST and OT should have contacted the physician and documented coordination of care and a verbal order for the ST and OT treatment plan and visit frequencies. Patient #7 A review of the POC dated 07/14/23 to 09/11/23 showed orders for PT evaluation (one time a week for one week, 07/14/23 to 07/15/23) and OT evaluation (one time a week for one week, 07/14/23 to 07/15/23). A PT evaluation dated 07/17/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed a PT reassessment dated 08/02/23 for an additional PT visit frequency of two times a week for two weeks, then one time a week for one week. Documentation showed PT visits were conducted 07/19/23, 07/24/23, 07/26/23, 07/31/23, 08/02/23, 08/08/23, 08/11/23, 08/14/23, 08/16/23 and on 08/25/23. Documentation showed no physician notification of the PT evaluation or reassessment, PT visit frequency recommendations or changes in physician orders. An occupational therapy evaluation dated 09/20/23 showed a recommended OT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed OT visits were conducted on 07/27/23, 07/28/23, 07/31/23, 08/04/23, 08/07/23, 08/11/23 and on 08/24/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:40 p.m., Staff A stated PT and OT should have contacted the physician and documented coordination of care and a verbal order for the PT and OT treatment plan and visit frequencies. Patient #11 A review of the POC dated 10/28/23 to 12/26/23 showed orders for PT evaluation (one time a week for one week, 10/28/23 to 11/02/23). A PT evaluation dated 11/01/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed PT visits were conducted 11/06/23, 11/08/23, 11/14/23, 11/16/23 and on 11/21/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. On 12/13/23 at 1:05 p.m., Staff A stated PT should have contacted the physician and documented coordination of care and a verbal order for the PT treatment plan and visit frequency.

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: 1. ST evaluation was conducted for one (Patient #1) of 17 patients; 2. OT visit were conducted as ordered for two (Patients #2 and #5) of 17 patients; 3. SN visit were conducted as ordered for two (Patients #4 and #6) of 17 patients; 4. CHHA visit were conducted as ordered for one (Patient #6) of 17 patients; 5. SN conducted weight assessments of two (Patients #10 and #17) of 17 patients and; 6. OT evaluation was conducted for one (Patient #11) of 17 patients. Findings: Patient #1 A review of the POC dated 06/04/23 to 08/02/23 showed an order dated 05/08/23 for ST to evaluate. Documentation showed no ST evaluation, patient/caregiver refusal of ST evaluation, physician notification and no change in orders. On 12/13/23 at 12:05 p.m., Staff A stated the patient #1 had no ST evaluation from the 05/08/23 physician order. Patient #2 A review of the POC dated 08/05/23 to 10/03/23 showed OT visit frequency of one time a week for one week, two times a week for two weeks. Documentation showed OT visits were conducted on 08/23/23 and on 08/25/23. During the week of 08/25/23 to 08/31/23 a missed visit (OT discipline discharge visit) was documented on 08/30/23 as discontinue due to patient non-compliance. Documentation showed no physician notification of the OT missed visit (OT discipline discharge visit) on 08/30/23, patient non-compliance and change in physician orders. On 12/13/23 at 12:10 p.m., Staff A stated OT should have documented the coordination of care physician contact related to patient non-compliance with OT and missed OT visit frequency. Patient #4 A review of the POC dated 09/10/23 to 11/08/23 showed orders for SN visit frequency of three times a week for three weeks, two times a week for two weeks, and then one time a week for four weeks. Documentation showed during the weeks of 09/23/23 to 09/29/23 SN visits were conducted 09/27/23 and 09/29/23 (three visit ordered, two visits conducted) and 10/06/23 to 10/12/23 SN visits were conducted 10/09/23 (missed visit) and 10/11/23 (three visit ordered, one visit conducted), Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 12/13/23 at 12:22 p.m., Staff A stated SN should have conducted SN visits as ordered in the POC. Patient #5 A review of the POC dated 10/24/23 to 12/22/23 showed OT visit frequency of one time a week for one week, then two times a week for two weeks. Documentation showed during weeks of 11/04/23 to 11/10/23 OT visits were conducted on 11/06/23 (two visits ordered, one visit conducted. Documentation showed no patient/caregiver refusal of care, physician notification and no change in orders. On 12/13/23 at 12:30 p.m., Staff A stated OT should have conducted OT visits as ordered in the POC. Patient #6 A review of the POC dated 07/27/23 to 09/24/23 showed orders for SN visit frequency of two times a week for three weeks, then one time a week for five weeks and CHHA visit frequency of two times a week for four weeks. Documentation showed during week of 08/05/23 to 08/11/23 no CHHA visit was conducted (one visit ordered, no visit conducted), 08/12/23 to 08/18/23 no SN visit was conducted (one visit ordered, no visit conducted) and no CHHA visit was conducted (one visit ordered, no visit conducted) and 08/19/23 to 08/25/23 no CHHA visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of care, physician notification and no change in orders. On 12/13/23 at 12:35 p.m., Staff A stated SN and CHHA should have conducted SN and CHHA visits as ordered in the POC. Patient #10 A review of the POC dated 03/06/23 to 05/04/23 showed orders for SN to assess, monitor and instruct patient’s weight every visit and notify physician of weight gain of 5 pounds in 2 weeks. Documentation showed during SN visits on 03/10/23 and on 03/16/23 no weight assessment was conducted. Documentation showed no patient/caregiver refusal of care, no physician notifications and no change in orders. On 12/13/23 at 12:50 p.m., Staff A stated the SN should have assessed the patient’s weight during SN visits as ordered in the POC. Patient #11 A review of the POC dated 10/28/23 to 12/26/23 showed orders for OT evaluation (one time a week for one week, 10/28/23 to 11/02/23). Documentation showed no OT evaluation was conducted. Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 12/13/23 at 1:05 p.m., Staff A stated OT should have conducted an evaluation as ordered in the POC. Patient #17 A review of the POC dated 11/21/23 to 01/19/24 showed orders for SN to assess, monitor and instruct patient’s weight every visit and notify physician of weight gain of 5 pounds in 1 weeks. Documentation showed during SN visits on 11/24/23, 12/01/23, 12/04/23 and on 12/11/23 no weight assessment was conducted. Documentation showed no patient/caregiver refusal of care, no physician notifications and no change in orders. On 12/13/23 at 1:50 p.m., Staff A stated the SN should have assessed the patient’s weight as ordered in the POC during SN visits.

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 SN visit note documentation was complete for two (Patients #13 and #15) of 17 patients. Findings: Patient #13 A review of the POC dated 11/10/23 to 01/08/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. Documentation showed SN visits were conducted daily from 11/10/23 to 12/11/23 (32 visits through date of the POC review) for SN to administer Basaglar (diabetic medication) subcutaneous injection daily. Documentation showed during SN visits dated 11/10/23, 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/25/23, 12/01/23, 12/02/23, 12/03/23, 12/04/23, and on 12/05/23 no documentation of what medication was administered, administered dose and/or subcutaneous injection site. On 12/13/23 at 1:15 p.m., Staff A stated the SN visit notes dated 11/10/23, 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/25/23, 12/01/23, 12/02/23, 12/03/23, 12/04/23, and on 12/05/23 should have documented what medication was administered, administered dose and the subcutaneous injection site. Patient #15 A review of the POC dated 11/16/23 to 01/14/23 showed a SN visit frequency of one time a week for one week, then two times a week for eight weeks for SN to perform wound site care to left lower extremity. Documentation during SN visits conducted on 11/20/23, 11/24/23, 11/27/23, 11/30/23, 12/04/23 and on 12/07/23 showed no type of wound site cleansing solutions or dressing materials that were utilized. On 12/13/23 at 1:25 p.m., Staff A stated wound site cleansers and dressing materials utilized for wound care to the left lower extremity during SN visits conducted on 11/20/23, 11/24/23, 11/27/23, 11/30/23, 12/04/23 and on 12/07/23 should have been documented.

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 transfer/discharge summary was provided for three (Patients #1, 2 and #6) of eight patients. Findings: Patient #1 A review of the clinical record documented transfer from the agency on 06/14/23. Documentation showed no discharge summary was provided to the physician service provider. Patient #2 A review of the clinical record documented transfer to inpatient service provider with subsequent discharge from the agency on 09/20/23. Documentation showed no transfer/discharge summary was provided to the inpatient service provider. Patient #6 A review of the clinical record documented transfer to inpatient service provider on 09/15/23. Documentation showed no transfer summary was provided to the inpatient service provider. On 12/13/23 at 12:05 p.m. to 12:35 p.m., Staff A stated no transfer summary was sent to the receiving service providers for Patients #1, 2 and #6.

The Oklahoma State Department of Health conducted an unannounced Medicare complaint survey (OK00057508) at the agency on 08/24/21. 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 and administrative 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 complaint survey. Glossary: PT physical therapy POC plan of care SN skilled nurse ROC Resumption of Care

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 physician orders were obtained for: 1. physical therapy visit frequency for two (Patient #3 and #4) of five patients and; 2. skilled nurse visit frequency for one (Patient #3) of five patients. Findings: Patient #3 A review of the clinical record showed the patient was transferred to in-patient hospital services and placed on agency hold on 7/02/21. Documentation showed no resumption of care after the patient was discharged from in-patient services on 07/05/21 and no physician orders for agency services to resume. SN visits were conducted on 07/09/21 and 07/13/21 (two visits conducted, no visits ordered) and physical therapy visits were conducted on 07/08/21, 07/13/21 and on 07/16/21 (three visits conducted, no visits ordered). Patient #4 A review of a POC dated 07/17/21 to 09/14/21 showed a physical therapy evaluation frequency of one time a week for one week. Documentation showed no communication with the physician and no physician orders beyond the one week one for evaluation. A review of the clinical record showed PT visits were conducted on 07/22/21 and 07/27/21 and an additional PT evaluation was conducted on 07/29/21 (three visits conducted, no visits ordered.) On 08/24/21 at 2:00 p.m., Staff A stated: 1. Patient #3 should have had a ROC assessment after the in-patient hospital discharge and the SN and PT visits that were ordered prior to the in-patient hospital transfer should not have been continued and; 2. PT should have documented a verbal order from the physician for the PT visit frequency for Patient #4.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of patient request to place home health services on hold for one (Patient #2) of five patients. Findings: Patient #2 A review of a POC dated 07/13/21 to 09/10/21 showed orders for SN visits at two times a week for five weeks and home health aide visits at one time a week for four weeks. A review of the clinical record showed no agency services occurred after 08/20/21 when the patient requested no further home health services until after a planned surgical procedure on 09/10/21. Documentation showed no physician notification of patient request to place home health services on hold and no change in orders. On 08/24/21 at 2:00 p.m., Staff A stated the physician should have been notified the patient requested no further home health services.

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 734 patients and all employees. Findings: A review of administrative records showed no data collection activities utilized in an agency QAPI Program for 1st and 2nd quarters in calendar year 2021. On 08/24/21 at 2:00 p.m., Staff A stated there were no QAPI records which showed analysis of data collected for 1st and 2nd quarters in calendar year 2021.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 01/05/21 to 01/07/21. A deficiency was cited as a result of the Medicare Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the review/revision of the community-based risk assessment (All Hazards Risk Assessment) for all employees and 564 current patients Findings: A review of agency administrative records and emergency preparedness records showed a facility-based and community-based risk assessment from 2017 that did not show a review or revision since it's development. Documentation showed no review or update of the community-based risk assessment for calendar years 2018, 2019 or 2020. On 01/-7/20 at 09:10 am, Staff C stated the only All Hazards Risk Assessment at the agency was completed 08/23/17.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with a complaint (OK00052913) at the agency on 01/05/21 - 01/07/21. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff C was identified as the contact person for administrative issues and Staff B was identified as the contact person 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 re-certification survey. No deficiencies were cited as a result of the complaint survey GLOSSARY: HHA Home Health Aide IM Intramuscular IV Intravenous L Liters NC Nasal Cannula POC Plan of Care PRN As needed Pt/Pts Patient/Patients SN Skilled Nurse

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was performed within 48 hours of the referral for one (Pt #1) of seventeen patients. Findings: Pt #1 A review of the clinical record showed a patient referral dated 07/08/20. Documentation showed an initial patient assessment and SOC dated 07/23/20 (fifteen days later). Documentation showed no physician or patient request to delay the initial assessment. On 01/07/21 at 10:12 am, Staff C stated the initial assessment for Pt #1 was not completed within 48 hours of the referral and there was no order or patient request documented to delay admission.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure POC orders included: 1) the reason for PRN SN visits for six (Pt #1, 2, 9,10, 13 and 14) of seventeen patients; 2) VS and/or pain parameters for two (Pt #2 and 3) of seventeen patients; 3) the correct medication route instructions for one (Pt #4) of seventeen patients; 4) oxygen use for two (Pt #5 and 13) of seventeen patients; 5) frequency of pressure ulcer measurements for one (Pt #6) of seventeen patients; 6) indwelling foley catheter size and the bulb size of the catheter to be inserted for one (Pt #6) of seventeen patients 7) a SN frequency for one (Pt #14) of seventeen patients. Findings: Pt #1 A review of the POC dated 11/20/20 to 01/18/21 showed a SN frequency of once a week for nine weeks and 3 visits PRN with no reason for staff to perform the PRN visits. Pt #2 A review of the POC dated 11/18/20 to 01/16/21 showed a primary diagnosis of essential hypertension with no VS parameters. Documentation showed SN visits to be completed once a month for two months and three visits PRN. Documentation showed no reason for staff to perform the PRN visits. Pt #3 A review of the POC dated 12/20/20 to 01/20/21 showed a primary diagnosis of chronic pain syndrome with no pain parameters or VS paramers to notify the physician. Pt #4 A review of the POC dated 11/19/20 to 01/17/21 showed orders in the medication section for the route of synagis (a medication) administration to be IM. POC oders for discipline and treatment showed the ordered route of administration for synagis was IV. Documentation showed no clarification for the route discrepancy. Pt #5 A review of the POC dated 12/19/20 - 02/16/21 showed no orders for oxygen. SN notes dated 12/19/20, 12/21/20, 12/22/20, 12/23/20 and 12/28/20 documented the use of oxygen. Pt #6 A review of the POC dated 11/19/20 to 01/07/21 showed a primary diagnosis of a pressure ulcer of sacral region stage 4 with no orders for weekly wound measurements. Clinical documentation showed the pressure ulcer was only measured 11/16/20, 12/14/20, 12/28/20 and 01/05/21 (four out of nine weeks). The POC showed orders for the SN to change the foley catheter monthly with no orders for the size of the catheter and the size of bulb to insert. Pt #9 A review of the POC dated 12/09/20 to 02/06/21 showed a SN frequency of twice a week for two weeks, once a week for six weeks and 3 visits PRN with no reason for staff to perform the PRN visits. Pt #10 A review of the POC dated 10/22/20 to 12/20/20 showed a SN frequency of once a week for nine weeks and 3 visits PRN with no reason for staff to perform the PRN visits. Pt #13 A review of the POC dated 12/10/20 to 02/07/21 showed: 1) no orders for oxygen, SN notes dated 12/10/20, 12/12/20, 12/16/20 documented the use of oxygen at 2 L/NC; 2) a SN frequency of twice a week for one week, seven times a week for one week, five times a week for one week, three times a week for three weeks, once a week for four weeks and 3 visits PRN with no reason for staff to perform the PRN visits. Pt #14 A review of the POC dated 11/15/20 to 01/13/21 had no ordered SN frequency. On 01/07/20 at 11:14 am, Staff C stated the POC should include: 1) the reason for PRN visits for Pts #1, 2, 9,10, 13 and 14; 2) VS and/or pain parameters for Pts #2 and 3; 3) the correct route for medications Pt #4; 4) orders for oxygen for Pts #5 and 13 of seventeen patients; 5) the frequency of pressure ulcer measurements for Pt #6; 6) indwelling foley catheter size and the bulb size of the catheter to be inserted for Pt #6; 7) a SN frequency for Pt #14.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1) the ordered frequencies were followed for one (Pt #7) of seventeen patients; 2) wound care was completed as ordered for one (Pt #11) of seventeen patients; 3) ordered measurements were completed for one (Pt #11) of seventeen patients. Findings: Pt #7 A review of the POC dated 10/12/20 to 12/10/20 showed a SN frequency of once a month for two months and a HHA frequency of once a week for eight weeks. Clinical documentation showed no SN or HHA visits were completed. Pt #11 A review of the POC dated 11/04/20 to 01/02/21 showed orders for SN to complete wound care on Saturday and Sunday (pt went to wound care clinic during the week). On 11/21/20 a missed visit was completed due to the patient not having wound supplies. On 11/22/20 a missed visit was completed due to not having supplies at the office. Documentation showed no nursing or agency intervention to ensure wound care was completed as ordered. Pt #13 A review of the POC dated 12/10/20 to 02/07/21 showed orders for SN to measure ankle/calf at each visit. Documentation show no ankle and calf measurements at the visits completed 12/11/20, 12/12/20, 12/13/20, 12/15/20, 12/16/20, 12/17/20, 12/18/20, 12/19/20, 12/20/20 and 12/21/20. On 01/07/21 at 10:54 am, Staff C stated: 1) Missed visits with physician notification should have been completed for Pt #7 2) The nurse should have notified the on call supervising nurse to go to the office and obtain the wound supplies needed for Pt #11; 3) Staff did not document measurements at all visits and the measurements should have been completed.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an order was obtained by a physician foran increased SN frequency for one (Pt #6) of 17 patients. Findings: Pt #6 A review of the POCdated 11/09/20 - 01/07/21 showed a SN ordered at a frequency of once a week for one week, seven times a week for one week and then once a week for one week (a total of nine visits). A review of clinical notes showed SN visits completed 11/09/20, 11/10/20, 11/11/20, 11/12/20, 11/13/20, 11/16/20, 11/17/20, 11/18/20, 11/19/20, 11/20/20, 11/21/20, 11/22/20, 11/23/20, 11/24/20, 11/25/20 11/27/20, 11/28/20, 11/29/20, 11/30/20, 12/01/20, 12/02/20, 12/03/20, 12/04/20, 12/05/20, 12/06/20, 12/07/20, 12/08/20, 12/09/20, 12/10/20, 12/11/20, 12/12/20, 12/13/20, 12/14/20, 12/16/20, 12/17/20, 12/18/20, 12/19/20, 12/20/20, 12/21/20, 12/23/20, 12/28/20, 12/29/20, 12/30/20, 12/31/20, 01/02/20, 01/03/20 and 01/04/20. Documentation showed no orders for additional visits, no changes in the ordered frequency and no patient requests for additional visits. On 01/07/21 at 2:32 pm, Staff C stated there was no order to increase the SN frequency for Pt #6.

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 the physician was notified of missed visits for two (Patient #7 and 14) of seventeen patients. Findings: Pt #7 A review of the POC dated 10/02/20 to 12/10/20 showed a HHA frequency of once a week for eight weeks. A review of clinical notes showed no HHA visits were completed. Documentation showed no patient refusal of visits, no missed visit notes, and no change in the ordered frequency documented in the clinical record. Pt #14 A review of the POC dated 11/15/20 to 01/13/21 showed a frequency of twice a week for four weeks effective 12/02/20. A review of clinical documentation showed one visit completed the week of 12/02/20 to 12/04/20 (one visit missing). Documentation showed no patient refusal of visits, no missed visit note or change in ordered frequency. On 01/07/21 at 10:44 am, Staff C stated the clinical manager should have been notified of missed visits for Pt #7 and a missed visit note should have been completed for Pt #14.