Every finding on record at Jane Phillips Regional Home Care, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 03/24/21 - 03/25/21. 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 03/24/21 - 03/25/21. 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 was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B and by telephone with Staff C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: COPD Chronic Obstructive Pulmonary Disease DME Durable Medical Equipment OT Occupational Therapy POC Plan of Care Pt Patient PT Physical Therapy ROC Resumption of Care SN Skilled Nurse

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 POC orders included oxygen use for one (Pt #1) of seventeen patients. Findings: Pt #1 A review of the POC dated 01/13/21 to 03/13/21 showed no orders for oxygen. Clinical SN notes dated 01/13/21, 01/19/21, 01/21/21 and 01/26/21 documented the use of oxygen; Clinical PT notes dated 01/21/21 and 01/26/21 documented the use of oxygen. A review of physician orders showed no orders for the use of oxygen from 01/13/21 to 03/13/21. On 03/25/20 at 12:26 pm, Staff A stated the POC should include orders for oxygen for Pt #1.

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 physician orders and/or notification of: 1) further PT frequency orders for one (Pt #2) of seventeen patients; 2) further PT frequency orders following the ROC orders for one (Pt #6) of seventeen patients; 3) further OT frequency orders for one (Pt #9) of seventeen patients; 4) notification of missed visits for one (Pt #9) of seventeen patients. Findings: Pt #2 A review of a POC dated 12/29/20 to 02/26/21 showed a PT frequency of once a week for one week effective the week of 01/03/21. Documentation showed PT visits completed 01/08/21, 01/12/21, 01/14/21, 01/21/21 and 01/26/21 (three extra visits). Documentation showed no change in the ordered PT frequency. Pt #6 A review of a POC dated 01/28/21 to 03/28/21 showed a ROC completed 02/13/21 with no documentation of the PT frequency on the ROC orders. Pt visits were documented 02/18/21, 02/24/21, 02/26/21, 03/02/21, 03/04/21, 03/09/21, 03/16/21, 03/18/21 and 03/23/21 with no orders for visits. Pt #9 A review of a POC dated 02/11/21 to 04/11/21 showed an OT frequency of once a week for one week effective the week of 02/28/21 and a home health aide frequency of twice a week for four weeks effective the week of 02/14/21 . Clinical documentation showed OT visits completed 03/05/21, 03/09/21, and 03/23/21 (two extra visits) and missed visit notes completed by the aide on 02/16/21, 02/19/21 and 03/02/21. Documentation showed no change in the ordered OT frequency, no orders for additional visits and no physician notification of the missed home health aide visits. On 03/25/21 at 1:18 pm, Staff B stated the documentation did not show: 1) a change in the PT frequency for Pt #2; 2) a PT frequency on the ROC orders for Pt #6; 3) an OT frequency for Pt #9; 4) physician notification of missed home health aide visits for Pt #9.