Every finding on record at Mdr Health Group, LLC

The Oklahoma Department of Health conducted an unannounced Emergency Preparedness Program survey at the agency on 12/05/23 to 12/06/23. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma Department of Health conducted an unannounced Medicare re-certification survey at the agency on 12/05/23 to 12/06/23. An entrance conference was conducted with the Administrator. The survey process was explained. Questions were answered. The Administrator was identified as the contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with the Administrator and Supervisory staff member. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: RN Registered Nurse SN Skilled Nurse POC Plan of Care SOC Start of Care

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 provide an individualized POC to include oxygen interventions, goals, equipment and safety measures necessary to meet the patient's assessed needs for one (#8) of eight (#1- #8) records reviewed. Patient #8 A review of the POC for Patient #8 for re-certification periods 11/08/23 to 01/06/23 revealed a primary diagnosis of Essential Hypertension and the Medication List included Oxygen 3 liters/minute via Nasal Cannula PRN QHS and with SOB. Review of the SN Visit Note for 11/29/23 documented Pt #8 has Supplemental Oxygen for PRN SOB. Further review of the POC failed to identify any diagnosis of supplemental oxygen or to include interventions, goals, DME equipment or safety measures specific to Oxygen. On 12/06/23 at 3:00 PM, the Administrator stated the Agency failed to update the POC and include patient specific oxygen diagnosis, interventions, goals, DME equipment and safety measures on the POC for Patient #8

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the RN failed to conduct onsite supervisory visits to the patient's home no less frequently than every 14 days for two (#2, and #7) of three (#2, #3 and #7) records reviewed with orders for Home Health Aide services. Patient #2 Review of the POC for recertification periods 09/01/23 - 12/29/23 revealed a Primary Diagnosis of Type II Diabetes Mellitus Pressure Ulcers and secondary diagnosis of Paraplegia with orders for Home Health Aide services 2 times a week for 1 week and 3 times a week for 8 weeks. Further review of RN documentation for Supervisory Aide Visits indicated onsite visits were conducted on 10/10/23 and 10/26/23 (2 days late). Patient #7 Review of the POC for recertification periods 08/09/23 - 12/06/23 revealed a Primary Diagnosis of Lubar Radiculopathy with orders for Home Health Aide services 3 times a week for 8 weeks and 2 times a week for 1 week. Further review of RN documentation for Supervisory Aide Visits indicated onsite visits were conducted on 09/12/23 and 09/27/23 (1 day late), 10/18/23 and 11/02/23 (1 day late). On 12/06/23 at 3:00 PM, the Administrator stated the RN failed to conduct Supervisory Aide Visits at least every 14 days as required for Pt#2 and Pt#7.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 01/19/21 to 01/20/21. 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 development of a community-based risk assessment (All Hazards Risk Assessment) for all employees and any future patients Findings: A review of agency administrative records showed no completion of a facility-based and community-based risk assessments that utilized an all hazards approach. On 01/20/21 at 9:14 am, Staff B stated she was not able to provide documentation of a facility-based and community-based risk assessment that utilized an all hazards approach for this agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency 01/19/21 to 01/20/21 An entrance conference was conducted with Staff A. The survey process was explained and questions were answered. Staff B was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. GLOSSARY: EMR Electronic Medical Record PIP Performance Improvement Project PIPs Performance Improvement Projects POC Plan of Care Pt Patient Pts Patients QAPI Quality Assessment Performance Improvement SN Skilled Nursing

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) Oxygen use for one (Pt #2) of seven patients; 2) Pain parameters for one (Pt #5) of seven patients. Findings: Pt #2 A review of the POC dated 12/10/20 - 02/07/21 showed no orders for the use of oxygen. SN notes dated 12/22/20, 01/02/21, 01/06/21 and 01/14/21 documented the use of oxygen. Pt # 5 A review of the POC dated 10/28/20 to 12/26/21 showed a secondary diagnoses of osteoarthritis, low back pain and pain in right hip, orders to assess pain at every visit, and no pain parameters for when to notify the physician of increased pain. SN notes documented high levels of pain (with no physician notification of elevated pain levels) on the following dates: 1) 11/17/20 - pain was a 10 out of 10; 2) 11/26/20 - pain was a 10 out of 10; 3) 12/01/20 - pain was a 7 out of 10; 4) 12/08/20 - pain was a 7 out of 10; 5) 12/12/20 - pain was a 7 out of 10; On 01/20/21 at 10:52 am, Staff B stated the POC should include: 1) Orders for oxygen for Pt #2; 2) Pain parameters for Pts #5

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 the skilled nurse notified the physician of vital signs outside of ordered parameters for one (Pt #5) of seven patients. Findings: Pt # 5 A review of the plan of care dated 10/28/20 to 12/26/20 showed orders to notify physician of: 1) Systolic blood pressure above 160; 2) Pulse greater than 100. A SN note dated 11/10/20 documented a blood pressure of 168/90 with no physician notification of the elevated systolic blood pressure. The following SN notes showed elevated heart rates with no physician notification: 1) 11/19/20 - heart rate 103; 2) 12/08/20 - heart rate 102; 3) 12/12/20 - heart rate 104; On 01/20/21 at 10:52 am, Staff B stated the skilled nurse should have notified the physician of elevated blood pressure and elevated heart rates for Pt #5.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversight of the agency programs for calendar year 2019 and 2020 for all employees and patients. Findings: A review of administrative records titled, "Rainbow Home Health, INC Board of Directors Meeting Minutes" for calendar year 2019 and 2020 showed no review and approval (for the agency being surveyed) of: 1) annual budget; 2) comprehensive QAPI program and PIP/PIPS; 3) policy and procedures. On 01/20/20 at 4:30 pm, Staff B stated governing body meeting minutes were for all Rainbow agencies and the calendar year 2019 and 2020 did not show approval and review of: 1) annual budget; 2) comprehensive QAPI Program and PIP/PIPS; 3) policy and procedures.