Every finding on record at Lifeline Home Health Care, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/17/24 to 06/18/24. 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 06/17/24 to 06/18/24. 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 issues and clinical issues, and Staff B was identified as an additional contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the survey. Glossary: CHHA certified home health aide MSW medical social work POC plan of care SN skilled nurse

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 notify the physician of changes in health conditions for three (Patients #1, 8 and #12) of 13 patients. Findings: Patient #1 A plan of care dated 04/03/24 to 06/01/24 documented diagnoses of chronic obstructive pulmonary disease. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report a weight loss of 3 pounds in a day or 5 pounds in a week to the physician. SN visit notes dated 04/09/24 and 04/16/24 documented the patient refused to be weighed. Documentation showed the patient had a weight of 181.2 pounds on 04/24/24 and a weight of 164 pounds on 05/29/24 (17-pound weight loss in 35 days). Documentation showed no physician provider notifications or coordination of care communications related to patient’s refusal to weigh or changes in the patient’s change in condition (17-pound weight loss in 35 days) and showed no changes in orders. On 06/18/24 at 1:32 p.m., Staff B stated the agency did not notify the physician of patient’s refusal to be weighed or changes in the patient’s condition (17-pound weight loss in 35 days). Patient #8 A plan of care dated 06/03/24 to 08/01/24 documented diagnoses of chronic kidney disease with hypertension. Documentation showed orders for SN to perform assessment and monitoring of patient’s blood sugar every visit and report a random blood sugar level greater than 200 to the physician. SN visit note dated 05/14/24 documented a random blood sugar of 239, visit note dated 05/17/24 documented a random blood sugar of 245, visit note dated 05/21/24 documented a random blood sugar of 278, and visit note dated 06/02/24 documented a random blood sugar of 209. Documentation showed no physician provider notifications or coordination of care communications related to patient’s continued elevated random blood sugar levels and showed no changes in orders. On 06/18/24 at 1:50 p.m., Staff B stated the agency did not notify the physician of the patient’s continued elevated random blood sugar levels. Patient #12 A plan of care dated 11/12/23 to 01/10/24 documented diagnoses of stage II pressure ulcer. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report weight less than 174 pounds to the physician. Documentation showed the patient had a weight of 160 pounds on 11/14/23 and a weight of 148 pounds on 12/22/23 (12-pound weight loss in 37 days). Documentation showed no physician provider notifications or coordination of care communications related to changes in the patient’s change in condition (12-pound weight loss in 37 days) and showed no changes in orders. On 06/18/24 at 1:32 p.m., Staff B stated the agency did not notify the physician of changes in the patient’s condition (12-pound weight loss in 37 days).

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: SN to conduct weight assessment and monitoring with physician reporting parameters for four (Patients #5, 8, 9 and 12) of 13 patients and; SN to conduct pain assessment and monitoring with physician reporting parameters for one (Patient #9) of 13 patients. Findings: Patient #5 A plan of care dated 04/23/24 to 06/21/24 documented diagnoses of chronic kidney disease with hypertension. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report a weight loss or gain of 3 pounds in a day or 5 pounds in a week to the physician. Documentation showed the patient had a weight of 97 pounds on 05/02/24 and a weight of 100 pounds on 05/03/24 (3-pound weight gain). Documentation showed no physician provider notifications or coordination of care communications related to patient’s weight gain in one day and showed no changes in orders. On 06/18/24 at 1:32 p.m., Staff B stated the agency did not notify the physician provider of patient’s weight gain of 3-pounds in one day. Patient #8 A plan of care dated 06/03/24 to 08/01/24 documented diagnoses of chronic kidney disease with hypertension. Documentation showed orders for SN and CHHA to perform assessment and monitoring of patient’s weight every visit and report a weight loss or gain of 3 pounds in a day or 5 pounds in a week to the physician. SN and CHHA visit notes dated 06/03/24, 06/04/24, 06/05/24, 06/07/24, 06/10/24, 06/11/24, 06/12/24 and 06/17/24 showed no patient weight assessment and were documented as NA (non-applicable). Documentation showed no physician provider notifications or coordination of care communications related to staff unable to weigh the patient, patient refusal of weight assessment and showed no changes in orders. On 06/18/24 at 1:50 p.m., Staff B stated the agency staff did not weigh the patient as ordered in the POC. Patient #9 A plan of care dated 05/01/24 to 06/29/24 documented diagnoses of vaginal bleeding. Documentation showed orders for SN and CHHA to perform assessment and monitoring of patient’s weight every visit and report a weight loss or gain of 3 pounds in a day or 5 pounds in a week to the physician and assess patient pain level and report to the physician provider of pain levels greater than five. SN and CHHA visit notes dated 05/09/24, 05/13/24, 05/14/24, 05/16/24, 05/20/24, 05/21/24, 05/23/24, 05/27/24, 05/28/24 and 06/03/24 showed no patient weight assessment and were documented as Ua (unable to weigh) or NA (non-applicable). Documentation showed no physician provider notifications or coordination of care communications related to staff unable to weigh the patient, patient refusal of weight assessment and showed no changes in orders; and SN visit notes dated 05/14/24, 05/28/24 and on 06/04/24 patient reported a pain level of seven. Documentation showed no physician provider notifications or coordination of care communications related to patient reported pain levels of seven and showed no changes in orders. On 06/18/24 at 1:55 p.m., Staff B stated: 1. The agency staff did not weigh the patient as ordered and; 2. The agency did not notify the physician provider of patient reported pain level of seven and showed no changes in the POC. Patient #12 A plan of care dated 11/01/24 to 12/30/24 documented diagnoses of right patellar fracture. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report a weight less than 174 pounds to the physician. SN visit notes dated 11/24/23, 12/01/23, 12/06/23, 12/15/23 and on 12/27/23 showed no patient weight assessment. Documentation showed no physician provider notifications or coordination of care communications related to patient weight assessment and showed no changes in orders. On 06/18/24 at 2:00 p.m., Staff B stated the agency staff did not weigh the patient as ordered in the POC.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of SN and MSW visit notes for one (Patient #13) of 13 patients. Findings: Patient #13 A review of the clinical record showed no documentation of a MSW visit conducted on 11/13/23 and a SN visit note for visit conducted on 12/21/23. Documentation showed an entry by the social worker in a coordination note (message) on 11/13/23 that the visit was conducted but showed no documentation of the visit note and SN visit conducted on 12/21/23 was blank and not marked as completed. On 06/18/24 at 2:00 p.m., Staff B stated no MSW visit note was documented for patient #3 for MSW visit conducted on 11/13/23 and the SN visit note for 12/21/23 was blank.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 08/04/21 to 08/05/21. 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 08/04/21 to 08/05/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons 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 and B. Deficiencies were cited as a result of the re-certification survey:

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 assessment was completed for one (Patient #2) of 17 patients. Findings: Patient #2 A review of the clinical record showed no discharge oasis assessment after the patient's last skilled nurse visit on 06/24/21. Documentation showed no communication notes, no discharge visit completed, no physician notification of patient discharge from the home health agency and no changes in orders. On 08/05/21 at 3:45 p.m., Staff B stated no in-patient transfer or discharge oasis assessment was conducted on Patient #2.

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 an individualized plan of care included accurate weight parameters for three (Patients # 15, 16, and 17) of 17 patients. Findings: Patient #15 A review of the plan of care dated 06/11/21 to 08/09/21 showed a primary diagnosis of multiple sclerosis and documented physician notification of weight greater than 30 pounds and weight less than 26 pounds. Patient #16 A review of the plan of care dated 06/26/21 to 08/24/21 showed a primary diagnosis of urinary tract infection and documented physician notification of weight greater than 35 pounds and weight less than 25 pounds. Patient #17 A review of the plan of care dated 06/24/21 to 08/22/21 showed a primary diagnosis of sepsis and documented physician notification of weight greater than 26.5 pounds and weight less than 22.5 pounds. On 08/05/21 at 3:40 pm, Staff B stated the weight parameters were supposed to be mid arm circumference measurements. Staff B stated the weight parameters for patients #15, 16 and 17 were inaccurate.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. the physician was notified of weights outside of ordered parameters for two (Patient #11 and 12) of 17 patients and 2. skilled nurse services were provided as ordered for one (Patient #11) of seven patients. Findings: 1. Patient #11 A review of the plan of care dated 06/17/21 to 08/15/21 showed orders to notify the physician of weight less than 184 pounds. A skilled nurse assessment dated 06/24/21 documented a weight of 179.5 pounds with no notification to the physician. A skilled nurse assessment dated 07/09/21 documented a weight of 170.5 pounds with no notification to the physician. A skilled nurse assessment dated 07/22/21 documented a weight of 172 pounds with no notification to the physician. A review of the plan of care dated 05/14/21 to 08/12/21 showed orders to notify the physician of weight greater than 243 pounds. A skilled nurse assessment dated 07/09/21 documented a weight of 250 pounds with no notification to the physician. A skilled nurse assessment dated 07/12/21 documented a weight of 250 pounds with no notification to the physician. A skilled nurse assessment dated 07/14/21 documented a weight of 250 pounds with no notification to the physician. 2. Patient #11 A review of the plan of care dated 06/17/21 to 08/15/21 showed skilled nurse visits ordered at a frequency of two visits for one month and three visits for one month. A review of the clinical record showed the following: one skilled nurse visit completed on 06/24/21 from 06/17/21 to 06/30/21 (one missing visit); one skilled nurse visit completed on 07/09/21 and 07/22/21 from 07/01/21 to 07/31/21 (one missing visit). Documentation showed no orders for skilled nurse frequency changes, no patient/caregiver refusal of visits and no missed visit notes. On 08/05/21 at 2:36 pm, Staff B stated: 1) the physician should have been notified of the weights outside the ordered parameters for Patients #11 and 12 and 2) the skilled nurse frequency was not followed as ordered for Patient #11.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of significant weight loss outside of ordered parameters for one (Patient #11) of 17 patients. Findings: Patient #11 A review of the plan of care dated 06/17/21 to 08/15/21 documented a secondary diagnosis of chronic kidney disease and showed orders to notify the physician of weight less than 184 pounds. A skilled nurse assessment dated 06/24/21 documented a weight of 179.5 pounds (4.5 pounds below parameter) with no notification to the physician. A skilled nurse assessment dated 07/09/21 documented a weight of 170.5 pounds (13.5 pounds below the ordered parameter) with no notification to the physician. A skilled nurse assessment dated 07/22/21 documented a weight of 172 pounds (12 pounds below the ordered parameter) with no notification to the physician. On 08/05/21 at 2:36 pm, Staff B stated the physician should have been notified of significant weight loss outside the ordered parameters for Patient #11.