Every finding on record at Jackson County Memorial Hospital Authority

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 03/13/24 to 03/14/24. 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 at the agency on 03/13/24 to 03/14/24. An entrance conference was conducted with Staff A and B. 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, C, D, E, F and G. Deficiencies were cited as a result of the re-certification survey.

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: Patient #4 A review of the plan of care dated 01/04/24 to 03/03/24 showed a primary diagnosis of rectal abscess and showed no patient specific interventions or goals for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 02/16/24 to 04/15/24 showed a primary diagnosis of pneumonia and showed no patient specific interventions or goals for the management of the primary diagnosis. Patient #9 A review of the plan of care dated 02/04/24 to 04/03/24 showed a primary diagnosis of urinary tract infection and showed no patient specific interventions for the management of the primary diagnosis. On 03/14/24 at 1:30 pm, Staff A stated there were no patient specific interventions for the primary diagnosis for Patients #4, 7 and 9.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to review and revise an individualized Plan of Care for one (Patients #4) of ten patients. Patient #4 A review of the plan care dated 01/04/24 to 03/03/24 showed a home health aide frequency of one visit per week for one week and two visits per week for eight weeks. A review of the clinical record showed the following: A home health aide omitted visit (per patient/caregiver request) dated 01/09/24 and completed home health aide visit dated 01/11/24 for the week of 01/07/24 to 01/13/24 (one of two completed visits). A home health aide omitted visit (per patient/caregiver request) dated 01/16/24 and completed home health aide visit dated 01/18/24 for the week of 01/14/24 to 01/20/24 (one of two completed visits). A completed home health aide visit dated 01/23/24 and a home health aide omitted visit dated 01/25/24 (per patient/caregiver request) for the week of 01/21/24 to 01/27/24 (one of two completed visits). Home health aide omitted visits (per patient/caregiver request) dated 01/30/24 and 02/01/24 for the week of 01/28/24 to 02/02/24 (no completed visits). A completed home health aide visit dated 02/20/24 and a home health aide omitted visit dated 02/22/24 (per patient/caregiver request) for the week of 02/18/24 to 02/24/24 (one of two completed visits). No update were made to the plan of care to show the patients decreased need for home health aide services. On 03/14/24 at 1:30 pm, Staff A stated there were no updates made the plan of care to show the decreased need for home health aide services for Patient #4.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/12/21 to 04/13/21. 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 04/12/21 to 04/13/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B and C were identified as the contact person for administrative issues and Staff A was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C and D Standard level deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: BP Blood Pressure POC Plan of Care Pt Patient SN Skilled Nurse

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 a complete order was obtained for placement of a catheter for one (Pt #2) of ten patients. Findings: Pt #2 A review of the EMR showed a physician's order dated 03/03/21 for catheterization. The order did not specify what type of catheter, the size and bulb size for the catheter. On 04/13/21 at 11:35 am, Staff A stated there was no order documenting the type of catheter, the size and bulb size for the catheter for Pt #2.

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 an elevated BP for one (Pt #1) of ten patients. Findings: Pt #1 A review of the POC dated 03/03/21 to 05/01/21 showed a diastolic BP limit of 56 to 90. A review of SN note dated 03/15/21 showed a systolic BP of 92. Clinical documentation showed no physician notification of the elevated BP. On 04/13/21 at 11:23 am, Staff A stated there was no documentation of physician notification of elevated diastolic BP for Pt #1 and the physician should be notified of elevated diastolic BP.