Every finding on record at Med-Corp Home Health, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/16/23 to 10/17/23. No deficiencies were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare recertification survey at the agency on 10/16/23 and 10/17/23. An entrance conference was conducted with Staff A. 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 and C. Deficiencies were cited as a result of the Medicare recertification survey. GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects

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 for one (Patient #1) of 7 patients. Patient #1 A review of the plan of care dated 08/19/23 to 10/17/23 showed a primary diagnosis of Hemiplegia following a cerebral infarction affecting right dominant side and a secondary diagnosis of dementia with goals that included the patient to be knowledgeful of how to prevent skin breakdown and patient will be instructed on safety measures specific to the environment. A review of the clinical record showed skilled nurse assessments dated 08/24/23, 08/31/23, 09/07/23, 09/14/23, 09/21/23, 09/28/23, 10/05/23 and 10/13/23 which documented the patient being disoriented to time and place. On 10/17/23 at 1:20 pm, Staff A stated the goals were not patient specific to Patient #1's mental status.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the review of a PIP through their QAPI Program for 36 patients and all employees. A review of QAPI records showed review of a PIP dated 02/21/23. On 10/17/23 at 1:40 pm, Staff A stated the agency had no documented review of the PIP dated 02/21/23.