Every finding on record at Lifecare Oklahoma, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 04/14/25 to 04/16/25. 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 from 04/14/25 to 04/16/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff C, D and E were identified as contact people for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff C, D, E, F, G and H. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary CHHA certified home health aide EMR electronic medical record HHCOC home health change of care PT physical therapy POC Plan of Care SN skilled nurse SOC start of care ABD Abdominal

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 ABN or HHCOC notices were provided to two (Patients #11 and #12) of 14 patients. Findings: Patient #11 A review of the clinical record showed no advance notice of discharge, home health change of care notice, or physician communications prior to the patient’s discharge from the agency on 01/08/25 for no medical provider face to face requirement. On 04/14/25 at 11:20 a.m., Staff C stated there were no ABN or HHCOC notice or physician communications prior to discharge for Patient #11. Patient #12 A review of the clinical record showed no advance notice of discharge, home health change of care notice, or physician communications prior to the patient’s discharge from the agency on 04/01/25 for change in insurance provider, no authorization for services. On 04/16/25 at 11:22 a.m., Staff C stated there were no ABN or HHCOC notices or physician communications in the clinical record for Patient #12.

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 a SOC assessment was conducted within 48 hours of referral for two (Patients #6 and #14) of 14 patients. Findings: Patient #6 A review of the clinical record showed the agency received referral information on 04/03/25 and the SOC assessment occurred on 04/07/25 (4 days later). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 04/14/25 at 10:45 a.m., Staff C stated the SOC assessment should have been conducted within 48 hours of referral (by 04/05/25). Patient #14 A review of the clinical record showed the agency received referral information on 08/05/24 and the SOC assessment occurred on 08/09/24 (4 days later). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 04/14/25 at 11:26 a.m., Staff C stated the SOC assessment should have been conducted within 48 hours of referral (by 08/07/24).

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 a physician’s order was documented in its entirety for one (Patient #2) of 14 patients. Findings: Patient #2 A review of the POC dated 03/23/25 to 05/21/25 showed orders for SN frequency of: three times a week for one week, two times a week for one week, four times a week for one week, two times a week for two weeks, four times a week for one week, three times a week for one week, then one time a week for one week and for SN to conduct Dexcom G7 device replacement (type of glucose level monitor). Documentation showed no interventions or goals related to the Dexcom G7 device and showed no physician notification, coordination of care communications and no change in orders. On 04/16/25 at 10:20 a.m., Staff C stated there was no interventions or goals related to the Dexcom G7 device and no physician notification, coordination of care communications and no change in orders.

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 care was coordinated between the agency and physician for three (Patients #7, 8 and #13) of 14 patients. Findings: Patient #7 A review of the POC dated 02/04/25 to 04/04/25 showed a diagnosis of hypertension (elevated blood pressure). Documentation showed SN to assess, monitor blood pressure and report to the physician blood pressure less than 95/60 or greater than 150/90. SN visits dated 03/06/25 showed a reading of 160/90 and on 03/29/25 showed a reading of 155/73. Documentation showed the blood pressure readings were auto faxed to the physician by the electronic medical record system and showed no follow up physician communications or coordination of care notes related to patient continued elevated blood pressure and showed no changes in orders. On 04/16/25 at 10:45 a.m., Staff C stated the SN should have communicated the patient’s continued elevated blood pressure with the physician. Patient #8 A review of the POC dated 03/25/25 to 05/23/25 showed diagnoses of congestive heart failure and chronic kidney disease. The POC showed orders for SN to report to the physician weight reporting parameters of less than 217 pounds and greater than 227 pounds. SN visits dated 03/28/25 showed a reading of 230 pounds and on 04/07/25 showed a reading of 232 pounds. Documentation showed the weight readings were auto faxed to the physician by the electronic medical record system and showed no follow up physician communications or coordination of care notes related to patient continued elevated weight readings and showed no changes in orders. On 04/16/25 at 10:50 a.m., Staff C stated the SN should have communicated the patient’s continued weight gain with the physician. Patient #13 A review of the POC dated 02/07/25 to 04/07/25 showed a diagnosis of hypertensive chronic kidney disease. The POC showed orders for SN to report to the physician weight reporting parameters of less than 163 and greater than 173 and pulse (heart rate) of less than 60 and greater than 90. SN visits dated 03/17/25 showed a reading of 155 pounds and pulse of 120. Documentation showed the weight readings and pulse readings were auto faxed to the physician by the electronic medical record system and showed no follow up physician communications or coordination of care notes related to patient elevated weight and pulse readings and showed no changes in orders. On 04/16/25 at 11:26 a.m., Staff C stated the SN should have communicated the patient’s weight gain and elevated heart rate to the physician.

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. SN visits as ordered for one (Patient #4) of 14 patients. 2. Wound care as ordered for one (Patient #8) of 14 patients. 3. Therapy visits as ordered for one (Patient #10) of 14 patients. 4. Pain level outside of reporting parameter to the physician for one (Patients #12) of 14 patients. Findings: Patient #4 A review of the POC dated 02/12/25 to 04/12/25 showed orders for SN visit frequency and duration of one time a week for nine weeks. Documentation showed during week of 02/23/25 to 03/01/25 no SN visit was conducted (one visit ordered). Documentation showed no physician notification and no changes in orders. On 04/16/25 at 10:26 a.m., Staff C stated a SN visit should have been conducted as ordered by the physician. Patient #8 A review of the POC dated 03/25/25 to 05/23/25 showed orders for SN to perform wound care to the right hip: cleanse with Dakins solution, cover with calcium alginate and collagen and cover with an ABD dressing; and right ankle: cleanse with Dakins solution, cover with calcium alginate and cover with border foam dressing each visit. Documentation showed on 03/28/25 SN visit wound care to the right hip was cleansed with normal saline and covered with an ABD dressing, no wound care was documented to the right ankle. On 03/31/25 SN visit wound care to the right hip was cleansed with normal saline and covered with an ABD dressing. Documentation stated the wound site to the right ankle was healed. On 04/01/25 SN visit documentation showed wound care to the right ankle was cleansed with normal saline and covered with an ABD dressing. No wound care was documented to the right hip. On 04/07/25 SN visit documentation showed wound care to the right ankle was cleansed with normal saline and covered with an ABD dressing. No wound site care was documented to the right hip. Documentation showed no physician notification that orders were not followed and no changes in orders. On 04/16/25 at 10:50 a.m., Staff C stated wound care should have been conducted as ordered by the physician. Patient #10 A review of the POC dated 02/26/25 to 04/26/25 showed orders for PT visit frequency and duration of two times a week for two weeks, then one time a week for one week, effective 03/02/25. Documentation showed no PT evaluation and subsequent visits were conducted until 03/24/25 (PT evaluation and four visits were ordered, no evaluation and no subsequent visits conducted). Documentation showed no physician notification and no changes in orders. On 04/16/25 at 11:15 a.m., Staff C stated the PT should have conducted the evaluation and subsequent visits as ordered on the POC effective the week of 03/02/25. Patient #12 A review of the POC dated 03/22/25 to 05/20/25 showed orders for SN frequency and duration of one time a week for one week, three times a week for one week, two times a week for seven weeks, then one time a week for one week to: 1. assess the patient’s pain level 2, instruct pain management interventions and 3. report patient’s reported pain levels greater than 0 of 10 every visit. Documentation showed SN visits dated 03/28/25 reported a pain level of 3 of 10. Documentation showed no physician notification and no changes in orders. On 04/16/25 at 11:22 a.m., Staff C stated the SN should have contacted the physician and reported the patient’s pain level during the visits.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. 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 (Patient #11) of 14 patients. Findings: Patient #11 A review of the POC dated 11/13/24 to 01/11/25 showed orders for a CHHA visit frequency of one time a week for two weeks, then one time every two weeks for six weeks. A review of the clinical record showed CHHA supervisory visits were completed on 12/09/24 and 12/29/24 (20 days). On 04/16/25 at 11:20 a.m., Staff C stated the CHHA supervisory visits for patient #11 were not conducted 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 interviews, the agency failed to ensure transfer/discharge summaries were provided to receiving service providers within two days of notification of transfer/discharge for two (Patients #7 and #14) of 14 patients. Findings: Patient #7 A review of the clinical record showed transfer from the agency on 03/11/25 to inpatient hospital provider services. Documentation showed a transfer summary was provided to the receiving inpatient hospital service provider on 03/14/25 (3 days from notification of the patient transfer). On 04/16/25 at 10:45 a.m., Staff C stated the transfer summary was sent to the receiving hospital three days after the patient transferred to inpatient hospital service. Patient #14 A review of the clinical record showed discharge from the agency on 02/27/25 to hospice provider services. Documentation showed no transfer summary was provided to the receiving hospice service provider. On 04/16/25 at 11:26 a.m., Staff C stated there was no discharge summary sent to the receiving hospice service provider.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 06/28/22 to 06/29/22. 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 06/28/22 to 06/29/22. 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 issues and for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Deficiencies were cited as a result of the re-certification.

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 development of an individualized plan of care for two (Patients #3 and 8) of 17 patients. Patient #3 A review of the plan of care dated 10/05/21 to 12/03/21 showed a primary diagnosis of hypertensive heart with heart failure with no orders to obtain weights or weight parameters for which to to notify the physician of necessary changes. Patient #8 A review of the plan of care dated 04/26/22 to 06/24/22 showed a primary diagnosis of carbuncle of buttock with no orders to provide any care to the carbuncle of the buttock or orders for the assessment and observation of the carbuncle of the buttock. On 06/28/22 at 2:00 pm, Staff A stated the plan of care for Patients #3 and 8 were not fully developed in regard to the primary diagnosis.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the review and revision of the plan of care to reflect the status and needs for one (Patient #12) of 17 patients. Patient #12 A plan of care dated 04/13/22 to 06/11/22 showed a skilled nurse frequency of one visit for one day on 04/30/22, two visits per week for two weeks from 05/02/22 to 05/15/22, one visit per week for one week from 05/23/22 to 05/29/22 and one visit per week for one week from 06/06/22 to 06/11/22 and documented orders for the skilled nurse to observe and assess a stage II pressure ulcer to the sacral region at each visit. Skilled nurse assessments dated 04/23/22, 04/30/22, 06/11/22, 05/25/22 and 06/08/22 documented no presence of skin breakdown or skin issues. On 06/29/22 at 9:20 am, Staff A stated the plan of care was not updated to reflect the current status of Patient #12.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the accurate documentation of weights for one (Patient #12) of 17 patients. Patient #12 A plan of care dated 03/30/22 to 05/28/22 showed a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system. A review of the medical record showed the following: A skilled nurse assessment dated 03/30/22 documented a weight of 240 pounds. A skilled nurse assessment dated 04/05/22 documented a weight of 140.6 pounds (a 100.6-pound weight gain). A skilled nurse assessment dated 04/13/22 documented a weight of 240.6 pounds (a 100-pound weight loss). A skilled nurse assessment dated 04/26/22 documented a weight of 239 pounds. A skilled nurse assessment dated 05/02/22 documented a weight of 139 pounds (a 100-pound weight loss). A skilled nurse assessment dated 05/03/22 documented a weight of 239 pounds (a 100-pound weight gain). On 06/28/22 at 1:44 pm, Staff A stated the skilled nurse assessments with the significant weight losses were not accurately documented.