Every finding on record at Mercy Hospital Oklahoma City, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/18/26 to 03/20/26. No deficiencies were cited as a result of the Emergency Preparedness Program.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with a complaint ( #71781) survey at the agency on 03/18/26 to 03/20/26. An entrance conference was conducted with Staff A. Staff B was identified as the contact person for administrative issues and Staff A 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 unrelated to the complaint survey. Glossary: POC - Plan of Care PRN - As needed Pt - Patient SOC - Start of Care

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a POC was developed within 5 calendar days of the SOC visit for one (Pt #8) of seventeen patients. Findings: Pt #8 A review of the record showed a SOC assessment completed 03/09/26. Documentation showed no POC completed or available at surveyor's request for review. On 03/18/26 at 12:00 pm Staff B stated the POC had not been completed.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC addressed ongoing appointments at a wound care clinic weekly for one (Pt #7) of seventeen patients. Findings: Pt #7 A review of a POC dated 01/26/26 -03/26/26 showed orders for home health to see Monday, Wednesday, and Friday for wound care. Missed visit note dated 1/30/26, 02/06/26, 02/13/26, 02/27/26, 03/06/26showed visits missed due to patient appointments at the wound clinic 03/13/26. Documentation showed no other reason given. On 03/18/26 at 1:50 pm, Staff B stated we scheduled a visit every Friday in case a nurse needed to do wound care on Friday.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1) Orders were obtained to discontinue catheter care for one (Pt #4) of seventeen patients. 2) A current POC was provided to the Assisted Living Center for one (Pt #12) of three patients who resided in an assisted living center. Findings: Pt #4 A review off a POC dated 01/28/26 - 03/28/26 showed orders for the skilled nurse to change the urinary catheter every month and PRN irrigation of foley catheter when signs/symptoms indicated ( such as clogged, leaking, increased sediment). A review of the record showed the patient's physician discontinued the catheter 03/02/26 at an office visit. Documentation showed no discontinue orders related to the catheter. On 03/18/26 at 1:30 pm, Staff B stated we don't have orders regarding the catheter being discontinued for Pt #4 Pt #12 A review of the record showed no POC for the certification period of 03/07/26 - 05/05/26. . On 03/19/26 at 12:24 pm, Assisted Living Center Staff #1 stated we do not have the current POC for this patient.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/21/23 to 03/23/23. 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 in conjunction with a complaint survey for #71781 at the agency on 03/20/23 to 03/23/23. An entrance conference was conducted with Staff A, B, C, D, E and F. The survey process was explained. Questions were answered. Staff A, B and C were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff B, C, E, F and G. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary notice HHA Home Health Agency OT Occupational therapy PT Physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse SOC start of care

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 an advance notice of discharge was provided prior to being discharged from the agency for three (Patients #2, 13 and #16) of 17 patients. Findings: Patient #2 A review of the clinical record showed no coordination of care communications related to imminent discharge from agency services and showed no advance notice of discharge prior to discharge from the agency on 12/30/22 for a change in payer source. On 03/21/23 at 1:30 p.m., Staff A stated patient #2 should have received an advanced notice of discharge prior to being discharged from the agency. Patient #13 A review of the clinical record showed no coordination of care communications related to imminent discharge from agency services and showed no advance notice of discharge prior to discharge from the agency on 02/09/23 for unsafe environmental conditions. On 03/23/23 at 12:05 p.m., Staff B stated patient #13 should have received an advanced notice of discharge for unsafe environmental conditions prior to being discharged from the agency. Patient #16 A review of the clinical record no coordination of care communications related to imminent discharge from agency services and showed no advance notice of discharge prior to discharge from the agency on 11/02/22 for non-compliance. On 03/23/23 at 12:50 p.m., Staff B stated patient #16 should have received an advanced notice of discharge for non-compliance prior to being discharged from the agency.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to educate the patient on potential health outcomes related to refusal of care and services prior to agency discharge for three (Patients #13, 15 and #16) of 17 patients. Findings: Patient #13 A review of a plan of care for 01/02/23 to 02/22/23 showed an SN visit frequency of two times a week for two weeks, then one time a week for seven weeks. A review of visit notes showed missed SN visits on 01/12/23 and 01/30/23 with subsequent discharge from agency services via desk discharge (agency discharge without a visit) on 02/09/23 for unsafe environment that impeded the agency’s ability to provide care and services. Documentation showed no communication or education attempts to the patient for potential health outcomes related to unsafe environment that impeded the agency’s ability to provide care and services with subsequent discharge from the agency prior to the discharge date of 02/09/23. On 03/23/23 at 12:05 p.m., Staff B stated there was no documentation of attempts to educate the patient of potential health outcomes related to unsafe environment that impeded the agency’s ability to provide care and services prior to subsequent discharge from the agency. Patient #15 A review of a plan of care for 12/15/23 to 02/12/23 showed an SN visit frequency of one time a week for eight weeks. A review of visit notes showed missed SN visits on 12/28/22, 01/13/23 and 01/30/23 with subsequent discharge from agency services on 02/08/23 for non-compliance (refusal of visits). Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of SN visits with subsequent discharge from the agency for non-compliance prior to the discharge date of 02/08/23. On 03/23/23 at 12:30 p.m., Staff B stated there was no documentation of attempts to educate the patient of potential health outcomes related to refusal of SN visits prior to subsequent discharge from the agency for non-compliance. Patient #16 A review of a plan of care for 10/25/22 to 01/03/23 showed an SN visit frequency of four times a week for one week, then one time a week for eight weeks. A review of visit notes showed missed SN visits on 10/26/22, 10/28/22 and on 11/08/22 with subsequent discharge from agency services via desk discharge (agency discharge without a visit) on 11/10/22 for non-compliance (refusal of visits). Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of SN visits with subsequent discharge from the agency for non-compliance prior to the discharge date of 11/10/22. On 03/23/23 at 12:50 p.m., Staff B stated there was no documentation of attempts to educate the patient of potential health outcomes related to refusal of SN visits prior to subsequent discharge from the agency for non-compliance.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of patient's behaviors that impeded the HHA from providing care and services and to inform the physician of the patient’s imminent discharge from the agency for cause for three (Patients #13, 15 #16) of 17 patients. Findings: Patient #13 A review of a plan of care for 01/02/23 to 02/22/23 showed an SN visit frequency of two times a week for two weeks, then one time a week for seven weeks. SN visit notes dated 01/02/23, 01/05/23, 01/09/23, 01/11/23, 01/20/23, and on 01/27/23 documented no identified problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services, showed no documented physician notification of the patient's behaviors that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 02/09/23. On 03/23/23 at 12:05 p.m., Staff B stated there was no documentation of physician notification of the patient's behaviors that impeded the HHA from providing care and services and no physician notification of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 02/09/23. Patient #15 A review of a plan of care for 12/15/23 to 02/12/23 showed an SN visit frequency of one time a week for eight weeks. SN visit notes dated 12/22/22, 12/30/22, 01/05/23, 01/19/23 and on 01/26/23 documented no identified problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services, showed no documented physician notification of the patient's behaviors that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 02/08/23. On 03/23/23 at 12:30 p.m., Staff B stated there was no documentation of physician notification of the patient's behaviors that impeded the HHA from providing care and services and no physician notification of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 02/08/23. Patient #16 A review of a plan of care for 10/25/22 to 01/03/23 showed an SN visit frequency of four times a week for one week, then one time a week for eight weeks. SN visit notes dated 10/27/22 and on 11/02/22 documented no identified problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services, showed no documented physician notification of the patient's behaviors that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 11/10/22. On 03/23/23 at 12:50 p.m., Staff B stated there was no documentation of physician notification of the patient's behaviors that impeded the HHA from providing care and services and no physician notification of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 11/10/22.

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 one (Patient #7) of 17 patients. Findings: Patient #7 A review of the clinical record showed the agency received referral information on 02/19/23 and the start of care assessment occurred on 03/03/23 (12 days from date of referral). Documentation showed telephone contact attempts by the SN on 02/19/23 and on 02/20/23 but showed no patient/caregiver refusal of SOC assessment, no physician notification of a delay in start of care and no change in orders. On 03/23/23 at 9:35 a.m., Staff B stated the start of care assessment should have been conducted within 48 hours of referral or the physician should have been notified of the delay in the start of care.

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 review and interview, the agency failed to ensure completion of a discharge summary for one (Patient #13) of 17 patients. Findings: Patient #13 A review of the clinical record showed the patient was discharged from the agency on 02/09/23 via a desk discharge (no home visit) to care of self for unsafe environmental conditions. Documentation showed no discharge summary and no summary of care was provided to the patient/caregiver or physician. On 03/23/23 at 12:05 p.m., Staff B stated the agency: Had no coordination of care communications with the patient/caregiver or physician related to imminent discharge from the agency for unsafe environmental conditions that impeded the agency ability to provide care and services to the patient in the home environment and; The agency did not develop and provide a discharge summary to the patient/caregiver or physician at the time of discharge from agency services.

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 care was coordinated between the agency and physician for one (Patient #6) of 17 patients. Findings: Patient #6 A review of a plan of care dated 02/07/23 to 04/07/23 documented a primary diagnosis of ankle fracture and showed an OT visit frequency of two times a week for four weeks effective week of 02/14/23. A review of clinical documentation showed an OT discharge on 02/23/23 (eight visits ordered, four visits conducted [discharged two weeks early]). Documentation showed no physician coordination of care communications to notify of early service discipline discharge, no patient/caregiver refusal of service and no changes in orders. On 03/23/23 at 9:20 a.m., Staff B the clinical record showed no coordination of care communications to the physician to notify of early service discipline discharge and showed no patient/caregiver refusal of services.

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 services were provided as ordered for: 1. SN visit frequency as ordered by the physician for three (Patients #2, 5 and #10) of 17 patients and; 2. OT to conduct evaluation as ordered for one (Patient #6) of 17 patients. Findings: Patient #2 A review of the POC dated 01/02/23 to 03/02/23 showed orders for a SN visit frequency of three times a week for eight weeks. Documentation showed during weeks of 01/02/23 to 01/07/23 a SN visit was conducted on 01/02/23 (start of care) and on 01/06/23 (three visits ordered, two visits conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visits and no change in orders. On 03/21/23 at 1:50 p.m., Staff A stated documentation showed two SN visits were conducted/completed during the week of 01/02/23 to 01/07/23 and three visits were ordered. Patient #5 A review of the POC dated 02/07/23 to 04/07/23 showed orders for a SN visit frequency of one time a week for three weeks. Documentation showed during weeks of 02/12/23 to 02/17/23 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visits and no change in orders. On 03/21/23 at 2:32 p.m., Staff A stated documentation showed no SN visits were conducted/completed during the week of 02/12/23 to 02/17/23 and one visit was ordered. Patient #10 A review of the POC dated 02/26/23 to 04/26/23 showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed during weeks of 02/26/23 to 03/04/23 one SN visit was missed on 02/27/23 Monday and showed no attempts to make up the visit during that week were documented (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of visit, no physician notification of attempt to make up the missed visit and no change in orders. On 03/21/23 at 2:32 p.m., Staff A stated documentation showed no SN visits were conducted/completed during the week of 02/26/23 to 03/04/23 and one visit was ordered. Patient #6 A review of the clinical record showed agency receipt of an order dated 03/08/23 for an OT to evaluate with a visit frequency of one time a week for one week. Documentation showed an OT evaluation on 03/13/23 (the following Medicare week). Documentation showed no patient/caregiver refusal of visit, no physician notification of missed visits and no change in orders. On 03/23/23 at 9:20 a.m., Staff B stated OT should have conducted the evaluation during the week of 03/08/23 as ordered.

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 SN visit notes were completed for one (Patients #4) of 17 patients. Findings: Patient #4 A plan of care dated 01/10/23 to 03/10/23 documented a principal diagnosis of spina bifida with paraplegia. A review of visit notes showed a SN visit frequency of once a week for nine weeks. Documentation showed SN visits notes on 02/03/23 and on 02/24/23 were not completed and authenticated by the SN. On 03/21/23 at 2:15 p.m., Staff A stated visit notes a on 02/03/23 and on 02/24/23 were not completed and authenticated by the SN and visit notes are to be completed and signed by staff within 24 hour of the visit.

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 oversite of: 1. A patient centered QAPI Program; 2. Agency program evaluation for calendar years 2021 and 2022 and; 3. An operating budget and allocation of resources activities for calendar years 2021 and 2022 for all patients and staff. Findings: A review of administrative records showed no governing body oversite of an ongoing patient centered QAPI program, annual agency program evaluation or operating budget and allocation of resource activities for calendar years 2021 and 2022. On 03/21/23 at 3:00 p.m., Staff A stated there was no documentation for calendar years 2021 and 2022 which showed governing body oversight of the patient centered QAPI program, annual agency program evaluation or operating budget and allocation of resource activities specific to the agency.

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 two (Patients #14 and #17) of 17 patients. Findings: Patient #14 A review of the clinical record documented discharge from the agency on 01/26/23 to inpatient hospital provider services. Documentation showed no discharge summary was provided to the inpatient hospital service provider. Patient #17 A review of the clinical record documented discharge from the agency on 02/16/23 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. On 03/23/23 at 1:00 p.m., Staff B stated no discharge summary was sent to the receiving service providers for Patient #14 and #17.