Every finding on record at Mercy Hospital Ardmore, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/06/23 to 11/07/23. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan for the agency included updated current staff contact information for all patients and staff. Findings: A review of administrative records showed documentation the Emergency Preparedness Communication Plan included terminated staff contact information and did not include updated current staff contact information for the agency. On 11/07/23 at 1:00 p.m., Staff A stated the Emergency Preparedness Communication Plan for the agency included contact information for terminated staff and did not include updated current staff contact information.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 11/06/23 to 11/07/23. 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 Staff B was identified as the 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: POC Plan of Care SN skilled nurse

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 advance beneficiary notice was provided to one (Patient #9) of 11 patients. Findings: Patient #9 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 07/25/23. On 11/07/23 at 11:50 a.m., Staff B stated patient # 9 should have received an advance beneficiary notice prior to being discharged from the agency for a change in payer source.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure medication regimen changes were updated on the medication profile for one (Patient #5) of 11 patients. Findings: Patient #5 A review of the plan of care dated 09/26/23 to 11/24/23 documented a principal diagnosis of subdural hematoma. An order dated 10/06/23 documented Augmentin 875/125 mg (an antibiotic) every 12 hours times 10 days, Metoprolol 25 mg (an anti-hypertensive) two times a day for 15 days and Compazine 10 mg (an anti-nausea/vomiting) as needed. A review of the clinical record showed no update to the medication profile for the medications: Augmentin, Metoprolol and Compazine and showed no review for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. On 11/06/23 at 4:00 p.m., Staff B stated the medication profile for patient #5 should have been updated to include the ordered medications and reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a transfer/discharge summary contained necessary medical information at the time of patient transfer/discharge for two (Patients #1 and 6) of 11 patients. Findings: Patient #1 Documentation showed the patient was transferred to an inpatient hospital service provider on 10/29/23. A discharge/transfer assessment dated 10/29/23 showed no documentation of medical information related to the current course of illness and treatment, including a medications list, post discharge goals and treatment preferences. On 11/06/23 at 2:20 p.m., Staff B stated discharge/transfer assessment (summary) did not contain all required necessary medical information for patient #1. Patient #6 Documentation showed the patient was transferred to an inpatient hospital service provider on 08/07/23. A discharge/transfer assessment dated 08/07/23 showed no documentation of medical information related to the current course of illness and treatment, including a medications list, post discharge goals and treatment preferences. On 11/07/23 at 9:40 a.m., Staff B stated discharge/transfer assessment (summary) did not contain all required necessary medical information for patients #6.

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 individualized patient POC included: 1. Identification of wound care sites for one (Patient #1) of 11 and; 2. Reoccurring catheter change intervention due date or last change date for one (Patient #3) of 11 patients. Findings: Patient #1 A review of the POC dated 09/28/23 to 11/26/23 showed orders for SN to conduct wound site care interventions every visit. A review of the clinical record showed documentation of wound sites to the midline chest and left lower extremity. POC documentation showed no identified wound sites. SN visits conducted on 10/03/23, 10/05/23, 10/12/23, 10/17/23 and 10/25/23 documented wound site care interventions to the midline chest and left lower extremity. Documentation showed no physician notifications and no change in orders. On 11/06/23 at 2:20 p.m., Staff B stated POC for patient #1 did not identify the wound care intervention sites. Patient #3 A review of the POC dated 09/07/23 to 11/05/23 showed orders for SN to perform reoccurring catheter change intervention monthly. POC documentation showed no reoccurring catheter change intervention due date or date of last catheter change. Documentation showed no SN visits were conducted between 09/07/23 and 11/07/23. Documentation showed no patient/caregiver refusal of care, physician notifications and no change in orders. On 11/06/23 at 3:05 p.m., Staff B stated POC for patient #3 did not identify the reoccurring catheter change intervention due date or last change date.

Communication with all physicians CFR(s): 484.60(d)(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 physician notification of patient reported inoperable (broken) blood glucose monitor for one (Patient #11) of 11 patients. Findings: Patient #11 A review of a plan of care dated 08/04/23 to 10/02/23 documented a primary diagnosis of osteomyelitis left foot and ankle; and a secondary diagnosis of Diabetes Mellitus Type II with foot ulcer. POC documented SN to assess, monitor and report the patient’s blood glucose levels every visit for blood sugars less than 60 or greater than 300. SN visit notes dated 08/07/23, 08/10/23 and on 08/17/23 documented the patient reported his blood glucose monitor was broken and he was not monitoring his blood sugar levels. Documentation showed no physician notification of the patient's report of an inoperable (broken) blood glucose monitor and non-compliance with blood sugar monitoring and showed no change in orders. On 11/07/23 at 12:30 p.m., Staff B stated the physician should have been notified the patient reported his blood glucose monitor was broken and he was not monitoring his blood sugar levels.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: Administrative records of ongoing patient centered QAPI program data collection activities and analysis of data utilized in the agency's QAPI Program for calendar year 2022 and 01/01/23 to 11/07/23 showed no data collection sources, activities or analysis of data utilized in the agency's QAPI Program. On 11/07/23 at 2:00 p.m., Staff A stated QAPI program documentation showed no program improvement data activities and no analysis of collected data for calendar year 2022 and 01/01/23 to 11/07/23.

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 initiation and review of a PIP through their QAPI Program 01/01/23 to 11/07/23 for all patients and employees. Findings: Administrative records of an ongoing patient centered QAPI program showed no PIP through the QAPI Program for the agency for 01/01/23 to 11/07/23. On 11/07/23 at 2:00 p.m., Staff A stated the agency had no QAPI PIP records for 01/01/23 to 11/07/23.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure its infection control program included surveillance monitoring and reporting was included in QAPI program activities for all patients and staff. Findings: Administrative records of an ongoing patient centered QAPI program for the agency for calendar year 2022 and 01/01/23 to 11/07/23 showed no infection control program surveillance monitoring and reporting as a part of QAPI program. On 11/07/23 at 2:00 p.m., Staff A stated QAPI program documentation for the agency showed no infection control program surveillance monitoring and reporting for calendar year 2022 and 01/01/23 to 11/07/23.

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 conducted assessments of patients weight every visit for one (Patient #1) of 11 patients; 2. SN conducted reoccurring every month catheter change for one (Patient #3) of 11 patients; 3. SN visits were conducted for two (Patients #4 and 10) of 11 patients and; 4. SN conducted assessments of patients’ blood sugar levels every visit for three (Patients #5, 8 and 10) of 11 patients. Findings: Patient #1 A review of the POC dated 09/28/23 to 11/26/23 showed orders for SN to assess, monitor and instruct the patient’s weight every visit. Documentation showed no assessment or monitoring of the patient’s weight was conducted during SN visits on 10/17/23. Documentation showed no patient/caregiver refusal of assessment or monitoring of weight, no physician notifications and no change in orders. On 10/31/23 at 2:20 p.m., Staff B stated the SN should have conducted assessment and monitoring of the patient’s weight during the SN visits as ordered in the POC. Patient #3 A review of the POC dated 09/07/23 to 11/05/23 showed orders for SN to perform reoccurring catheter change intervention monthly. Documentation showed no SN visits were conducted between 09/07/23 and 11/07/23. Documentation showed no patient/caregiver refusal of care, physician notifications and no change in orders. On 11/06/23 at 3:05 p.m., Staff B stated documentation showed no SN visits between 09/07/23 and 11/07/23 for reoccurring catheter change intervention had been conducted. Patient #4 A review of a POC dated 09/23/23 to 11/21/23, showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed during the week 10/22/23 to 10/28/23 no SN visit was conducted (one visit ordered, no visit conducted or documented). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 11/06/23 at 3:40 p.m., Staff B stated the SN should have conducted and documented the SN visit as ordered in the POC. Patient #5 A review of the POC dated 09/26/23 to 11/24/23 showed orders for SN to assess, monitor and instruct the patient’s blood sugar levels every visit. Documentation showed no assessment or monitoring of the patient’s blood sugar levels was conducted during SN visits on 09/30/24 and on 10/02/23. Documentation showed no patient/caregiver refusal of assessment or monitoring of blood sugar levels, no physician notifications and no change in orders. On 11/06/23 at 4:00 p.m., Staff B stated the SN should have conducted assessment and monitoring of the patient’s blood sugar levels during the SN visits as ordered in the POC. Patient #8 A review of the POC dated 04/20/23 to 06/18/23 showed orders for SN to assess, monitor and instruct the patient’s blood sugar levels and report to physician readings outside of notification parameters. Documentation showed no assessment or monitoring of the patient’s blood sugar levels was conducted during SN visits on 04/24/23, 04/27/23, 05/01/23, 05/04/23, 05/11/23. 05/15/23 and on 05/18/23. Documentation showed no patient/caregiver refusal of assessment or monitoring of blood sugar levels, no physician notifications and no change in orders. On 11/07/23 at 11:40 a.m., Staff B stated the SN should have conducted assessment and monitoring of the patient’s blood sugar levels during the SN visits as ordered in the POC. Patient #10 A review of a POC dated 09/23/23 to 11/21/23, showed orders for a SN visit frequency of two times a week for four weeks. Documentation showed during the weeks of 04/23/23 to 04/29/23 a SN visit was conducted 04/26/23 (two visit ordered, one visit conducted or documented). During the weeks of 05/14/23 to 05/20/23 a SN visit was conducted 05/15/23 (two visits ordered, one visit conducted or documented). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 11/07/23 at 12:05 p.m., Staff B stated the SN should have conducted and documented the SN visits as ordered in the POC.

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 interview, the agency failed to ensure a completed discharge summary was provided for five (Patients #1 and 6) of 11 patients. Findings: Patient #1 A review of the clinical record documented transfer to inpatient hospital service provider on 07/26/23. Documentation showed no transfer summary was provided to the physician of record and the receiving inpatient hospital service provider. On 11/06/23 at 2:20 p.m., Staff B stated documentation showed no transfer summary was provided to the physician of record and the receiving service providers for patient #1 at the time of transfer from agency services. Patient #6 A review of the clinical record documented transfer to inpatient hospital service provider on 08/07/23. Documentation showed no transfer summary was provided to the physician of record and the receiving inpatient hospital service provider. On 11/07/23 at 9:40 a.m., Staff B stated documentation showed no transfer summary was provided to the physician of record and the receiving service providers for patient #6 at the time of transfer from agency services.