Every finding on record at Millennium Home Health Care, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 01/06/26 - 01/07/26. 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 and complaint survey (97207) at the agency 01/06/26 - 01/07/26. An entrance conference was conducted with Staff A, B, and C. The survey process was explained. 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 unrelated to the complaint survey. Glossary: LPN - Licensed Practical Nurse POC - Plan of Care Pt - Patient SN - Skilled Nurse

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 the ordered frequency was followed for one (Pt #2) of seven patients. Findings: Pt #2 A POC dated 07/29/25 to 09/26/25 showed orders for SN visits at a frequency of twice a week for one week, then once a week for eight weeks. A review of SN visit notes showed during week of 08/16/25 to 08/22/2 no visit conducted, one visit ordered. The clinical record showed no patient/family refusal of care and no physician's order to change SN visit frequencies. On 01/07/26 at 1:36 p.m., Staff B stated the SN frequency was not followed 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 clinical notes were complete in the clinical record for one (Pt #7) of seven patients. Findings: Pt #7 A POC dated 12/05/25 - 02/02/26 showed orders for SN visits at a frequency of once a week for nine weeks. A review of SN visit notes showed: 1) 12/21/25 - 12/27/25 a blank SN note dated 12/23/25. 2) 12/28/25 - 01/03/25 a blank SN note dated 12/30/25. On 01/07/25 at 1:29 p.m., Staff B stated the SN has 48 hours to complete their nurses note. There was no change in the physician ordered frequency, refusals, or missed visits documented.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an LPN supervisory visit was completed for one (Patients #1) of seven patients. Findings: Pt #1 A plan of care dated 10/29/25 to 12/27/25 showed a SN visit frequency of twice a week for nine weeks. A review of the clinical record showed SN visits completed on 10/29/25, 10/31/25, 11/05/25, 11/07/25, 11/11/25, 11/14/25, 11/19/25, 11/21/259, 11/26/25, 11/28/25, 12/03/25, 12/05/25, 12/10/25, 12/12/25, 12/17/25, 12/19/25, and 12/24/25 with no supervisory LPN visits conducted (60 days without supervisory visits). On 017/11/20 at 12:53 p.m., Staff B stated the LPN supervisory visits should have been completed at least every 60 days and none are present in the patient record.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/13/22 to 12/14/22. 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), §485.625(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 included required information related to the staff contact information for the agency affecting all patients and employees. Findings: A review of administrative records showed documentation of a staff contact list for an associated Hospice agency (name withheld) and showed no documentation the Emergency Preparedness Communication Plan included the staff contact information for the Home Health agency. On 12/14/22 at 2:30 p.m., Staff A stated the active staff member call list was not included in the Emergency Preparedness Communication Plan for the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 12/13/22 to 12/14/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D, E and F. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: CHHA certified home health aide HHA Home Health Agency PIP performance improvement project POC Plan of Care QAPI Quality Assessment Performance Improvement SN Skilled Nurse

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 transfer/discharge summary for two (Patients #6 and #9) of 13 patients. Findings: Patient #6 A review of the clinical record showed the patient was discharged from the agency as a desk discharge to hospice provider services on 12/02/22. Documentation showed no discharge summary. Patient #9 A review of the clinical record showed the patient was transferred from the agency to inpatient hospital provider services on 11/16/22. Documentation showed no transfer summary and no physician notification of the transfer. On 12/14/22 at 2:15 p.m., Staff A stated: 1. Patient #6 did not have a discharge summary and; 2. Patient #9 showed no transfer summary completed and showed no physician notification of the transfer from the agency.

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: 1. POC’s included: Recurring ostomy change intervention treatment due dates were documented for one (Patient #2) of 13 patients; Recurring urinary catheter change intervention treatment due dates were documented for one (Patient #4) of 13 patients and; 2. Individualized POC was completed after a start of care comprehensive assessment for one (Patient #9) of 13 patients. Findings: Patient #2 A review of the plan of care dated 10/17/22 to 12/10/22 documented a principal diagnosis of colon cancer with colostomy. POC orders directed SN to manage ostomy and perform treatment intervention of weekly colostomy device change. Documentation showed no treatment intervention due date or last completed treatment intervention date. On 12/14/22 at 1:25 p.m., Staff A stated recurring colostomy device treatment intervention change due dates should have been documented in the current POC episode dates for Patients #2. Patient #4 A review of the plan of care dated 09/17/22 to 11/13/22 documented a principal diagnosis of hemiplegia with cyst ostomy. POC orders directed SN to manage catheter urinary device and perform treatment intervention of monthly catheter change. Documentation no treatment intervention due date or last completed treatment intervention date. On 12/14/22 at 1:30 p.m., Staff A stated recurring urinary catheter treatment intervention change due dates should have been documented in the POC for Patients #4. Patient #9 A review of the clinical record showed a comprehensive start of care assessment was conducted on 11/09/22. Documentation showed no individualized POC had been completed. On 12/14/22 at 2:15 p.m., Staff A stated: 1. An individualized POC for Patients #9 was not completed and; 2. The patient was transferred/discharged to inpatient hospital provider services on 11/16/22.

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 quality indicator data to improve QAPI program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: Administrative records for calendar years 2020, 2021 and 01/01/22 through 12/13/22 were requested. No administrative records for calendar years 2020 and 2021 were provided. A review of administrative records showed no quality indicator data collection activities utilized in an agency QAPI Program for calendar years 2020, 2021 and 01/01/22 to 12/13/22. On 12/14/22 at 2:30 a.m., Staff A stated: 1. They had no analysis of quality indicator data collected available that showed improved quality of patient care and; 2. Program improvement data was not available.

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 for all patients and employees. Findings: Administrative records for calendar years 2020, 2021 and 01/01/22 through 12/14/22 were requested. No administrative records for calendar years 2020 and 2021 were provided. A review of QAPI records showed no documentation of the initiation, review, data analysis, or status of PIPs in calendar years 2020, 2021 and 01/01/22 to 12/13/22. On 12/14/22 at 2:30 p.m., Staff A stated the agency had no documentation which showed PIP activities for 2021 and 01/01/22 to 12/14/22.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities in calendar years 2020, 2021 and 01/01/22 through 01/24/22 for all patients and employees. Findings: Administrative records for calendar years 2020, 2021 and 01/01/22 through 12/13/22 were requested. No administrative records for calendar years 2020 and 2021 were provided. A review of administrative records showed no governing body oversite of ongoing QAPI program activities, including reporting and no quarterly QAPI meetings to improve the care, services, and operations of the agency for calendar years 2020, 2021 and 01/01/22 through 01/24/22. Documentation showed no COVID19 focused QAPI activities for calendar years 2020 and 2021. On 12/14/22 at 2:30 p.m., Staff A stated the agency had no documentation which showed governing body oversite of QAPI program activities for calendar years 2020 and 2021 and the governing body did not become aware of no QAPI program activities until 01/24/22.

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 on the POC’s: 1. SN to conduct visit frequency as ordered by the physician for five (Patients #1, 2, 3, 5 and #7) of 13 patients; 2. OT to conduct visit frequency as ordered by the physician for one (Patients #3) of 13 patients and; 3. SN to conduct assessment of patient blood pressure, record and report to the physician blood pressure levels outside of reporting parameters for two (Patient #7 and #10) of 13 patients. Findings: Patient #1 A review of a plan of care dated 10/12/22 to 12/10/22 documented a primary diagnosis of stage 2 pressure ulcer. Documentation showed a SN visit frequency of two times a week for one week, three times a week for two weeks, two times a week for one week, then one time a week for five weeks. Documentation showed no SN visit during the week of 11/20/22 to 11/26/22 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of SN visit, no physician notification of declined SN visit and no change in orders. Patient #2 A review of a plan of care dated 10/17/22 to 12/15/22 documented a primary diagnosis of colon cancer with colostomy. Documentation showed a SN visit frequency of one times a week for nine weeks. Documentation showed no SN visit during the week of 11/20/22 to 11/26/22 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of SN visit, no physician notification of declined SN visit and no change in orders. Patient #3 A review of a plan of care dated 10/31/22 to 12/29/22 documented a primary diagnosis of ALS. Documentation showed a SN visit frequency of two times a week for nine weeks and an OT visit frequency of one time a week for one week, then two times a week for five weeks. Documentation showed no SN visit during the week of 12/03/22 to 12/09/22 (one visit ordered, no visit conducted); and no OT visit during the weeks of 11/26/22 to 12/02/22 (two visits ordered, no visits conducted) and 12/03/22 to 12/09/22 (two visits ordered, no visits conducted). Documentation showed no patient/caregiver refusal of SN or OT visits, no physician notification of declined SN or OT visits and no change in orders. Patient #5 A review of a plan of care dated 10/19/22 to 12/17/22 documented a primary diagnosis of peripheral vascular disease. Documentation showed a SN visit frequency of one time a week for eight weeks. Documentation showed no SN visit during the weeks of 11/27/22 to 12/03/22 (one visit ordered, no visit conducted) and 12/04/22 to 12/10/22 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of SN visit, no physician notification of declined SN visit and no change in orders. Patient #7 A review of a plan of care dated 10/06/22 to 12/04/22 documented a primary diagnosis of hypertension. Documentation showed a SN visit frequency of one times a week for eight weeks and showed SN to assess patient blood pressure, record and report to the physician of change in patient blood pressure outside of reporting parameters of systolic pressure greater than 160. Documentation showed a blood pressure reading of 182/82 on SN visit dated 10/20/22 and no SN visit during the week of 11/28/22 to 12/04/22 (one visit ordered, no visit conducted). Documentation showed no physician notification of elevated systolic blood pressure level, no patient/caregiver refusal of SN visit, no physician notification of declined SN visit and no change in orders. Patient #10 A review of a plan of care dated 10/06/22 to 12/04/22 documented a primary diagnosis of hypertension. Documentation showed SN to assess patient blood pressure, record and report to the physician of change in patient blood pressure outside of reporting parameters of systolic pressure greater than 160. Documentation showed elevated blood pressure readings during SN visits dated: 11/04/22 173/82, 11/11/22 167/93, 11/21/22 163/76, 11/23/22 166/88, 11/25/22 167/82 and on 11/28/22 163/72. Documentation showed no physician notification of elevated systolic blood pressure levels and no change in orders. On 12/14/22 at 2:15 p.m., Staff A stated: 1. SN should have conducted visit frequencies as ordered by the physician for patients #1, 2, 3, 5 and 7; 2. OT should have conducted visit frequency as ordered by the physician for patients #3 and; SN should have reported to the physician blood pressure levels outside of the reporting parameter for patient #10.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure skilled professional multi-disciplinary staff were available to participate and provide input into the conduction of patient centered QAPI Program activities in calendar years 2020, 2021 and 04/01/22 through 12/14/22 for all patients and employees. Findings: Administrative records for calendar years 2020, 2021 and 01/01/22 through 12/13/22 were requested. No administrative records for calendar years 2020 and 2021 were provided. A review of administrative records showed no documentation of ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar years 2020, 2021 and 04/01/22 through 09/10/22. Documentation showed QAPI committee meetings for the agency on 09/11/22 and on 10/10/22 and showed no professional multi-discipline staff participation in the QAPI program activities for 04/01/22 through 12/13/22. On 12/14/22 at 2:30 p.m., Staff A stated the agency: 1. Could not provide administrative records which showed QAPI activities for calendar years 2020, 2021 and 04/04/22 through 09/10/22; 2. Identified the need for and put into place an agency wide QAPI program by 02/28/22 and; 3. The agency QAPI committee had no multi-disciplinary professional staff participation.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the development of a home health aide care plan for one (Patient #12) of 13 patients. Findings: Patient #12 A review of the clinical record showed no documented home health aide care plan for the episode of 10/26/22 through 12/24/22. POC documented a home health aide visit frequency of two times a week for eight weeks effective week of 10/31/22. Documentation showed home health aide visits were conducted on 11/01/22, 11/04/22, 11/08/22, 11/11/22, 11/15/22, 11/18/22, 11/22/22, 11/25/22, 11/29/22, 12/02/22, 12/06/22 and on 12/09/22. On 12/14/22 at 9:30 a.m., Staff C stated the clinical record for patient #12 showed no documented home health aide care plan.

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 for calendar years 2020, 2021 and 04/01/22 to 09/11/22; 2. An operating budget and allocation of resources activities for calendar years 2020 and 2021 and; 3. Agency program evaluation for calendar years 2020 and 2021 affecting all patients and staff. Findings: Administrative records for calendar years 2020, 2021 and 01/01/22 through 12/13/22 were requested. No administrative records for calendar years 2020 and 2021 were provided. A review of administrative records showed no documentation of governing body oversite of an ongoing patient centered QAPI program or operating budget and allocation of resource activities for calendar years 2020 and 2021 and no governing body review and oversite of an ongoing patient centered QAPI program for 04/01/22 to 09/11/22. On 12/14/22 at 2:30 p.m., Staff A stated there was no documentation which showed governing body oversight for the agency for calendar years 2020, 2021 and no QAPI program review and oversite for 04/01/22 to 09/11/22.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of a qualified alternate administrator for the agency affecting all patients and employees. Findings: Administrative records for calendar years 2020, 2021 and 01/01/22 through 12/13/22 were requested. No administrative records for calendar years 2020 and 2021 were provided. A review of administrative records for 01/01/22 through 12/13/22 showed appointment by the governing body of a non-certified person (name withheld) as the alternate administrator for the agency. On 12/13/22 at 11:50 a.m., Staff B stated she was the designated alternate administrator for the agency and the designated certified administrator for the agency was out of the country on vacation. A copy of an administrator’s certified for the alternate administrator was requested. Staff B stated she did not hold an administrator’s certificate and the agency did not think an alternate administrator for the agency had to be certified to direct the agency’s operations.

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 transfer/discharge summary was provided for two (Patients #6 and #8) of 13 patients. Findings: Patient #6 A review of the clinical record documented discharge from the agency on 12/02/22 to hospice provider services. Documentation showed no discharge summary was provided to the hospice services provider. Patient #8 A review of the clinical record documented transfer from the agency on 11/20/22 to inpatient hospital provider services. Documentation showed no discharge summary was provided to the inpatient hospital service provider. On 12/14/22 at 2:10 p.m., Staff A stated no transfer/discharge summaries for patients #6 and #8 were provided to the receiving service providers.