Every finding on record at Oldham Home Care LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 10/25/23 to 10/26/23. 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 at the agency on 10/25/23 to 10/26/23. An entrance conference was conducted with Staff A. The survey process was explained. 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. A deficiency was cited as a result of the re-certification survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the accuracy of the primary diagnosis documented on home health aide notes for one (Patient #2) of 7 patients. Patient #2 A review of the plan of care dated 08/04/23 to 10/02/23 showed a primary diagnosis of paroxysmal atrial fibrillation with a home health aide frequency of one visit per week for one week, two visits per week for eight weeks and one visit per week for one week. A review of the clinical record showed the following: A home health aide not dated 08/04/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 08/07/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 08/11/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 08/14/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 08/18/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 08/21/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 08/25/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 08/28/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/01/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/04/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/08/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/11/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/15/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/18/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/22/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/25/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 09/28/23 documented a primary diagnosis of acute posthemorrhagic anemia. A home health aide not dated 10/02/23 documented a primary diagnosis of acute posthemorrhagic anemia. On 10/26/23 at 1:50 pm, Staff B stated the primary diagnosis documented on the home health aide notes for Patient #2 was incorrect.