Every finding on record at Patience Home Health Care LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/24/23 to 10/25/23. Standard deficiencies were cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure a community based All Hazards Risk Assessment that identified the date of assessment development, implementation and review for all patients and employees. Findings: A review of administrative records showed no community-based risk assessment which identified the agency, showed a date of assessment, development, implementtion and review for the agency, its patient population, or its employees. On 10/25/22 at 1:00 p.m., Staff B stated the agency did not develop and implement an AHRA.

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 included updated staff contact information for the agency for all patients and staff. Findings: A review of administrative records showed no updated Emergency Preparedness Communication Plan to include current staff contact information for the agency. On 10/25/23 at 1:00 p.m., Staff B stated the Emergency Preparedness Communication Plan was not updated to include contact information for current staff of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/24/23 to 10/25/23. 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 clinical issues and Staff B was identified as the contact person for administrative issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the survey. Glossary: EP Emergency Preparedness HHA Home Health Agency OSDH Oklahoma State Department of Health OT Occupational therapy PIP Performance Improvement Project PT Physical therapy POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient forms for consent and acknowledgement of Patient Rights, billing, complaint and grievance processes were obtained and maintained in the patients clinical record for two (Patients #2 and 6 ) of seven patients reviewed. Findings: Patient #2 Review of the clinical patient record showed a SOC date of 08/09/23. Documentation showed no electronic or paper attachments of consent or acknowledgment receipt of Patient Rights, billing, complaint and grievance processes forms. Patient #6 Review of the clinical patient record showed a SOC date of 07/24/23. Documentation showed no electronic or paper attachments of consent or acknowledgment receipt of Patient Rights, billing, complaint and grievance processes forms. On 10/25/23 from 10:53 to 11:20 a.m., Staff A reviewed the clinical patient records and stated patients #2 and 6: 1. Did not have consents or acknowledgement receipt of Patient Rights, billing, complaint and grievance processes forms documented in their clinical patient records and; 2. Acknowledgement and consent form documentation for patients #2 and #6 should have been obtained at start of care and then scanned into their electronic clinical records.

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 physical therapy evaluation results for one (Patient #3) of seven patients. Findings: Patient #3 A review of a plan of care dated 09/22/23 to 11/09/23 documented a diagnosis of Diabetes Mellitus Type II. Documentation showed orders for a physical therapy evaluation only. A physical therapy evaluation note dated 09/28/23 showed a treatment plan with a frequency and duration of one time a week for one week, then two times a week for four weeks. Documentation showed no notification, communication and / or coordination of care with the physician and documented no additional orders for the physical therapy treatment plan. On 10/25/23 at 11:00 a.m., Staff B stated the physician should have been notified of the physical therapy evaluation findings to obtain treatment orders.

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: A review of QAPI records for calendar years 2021, 2022 and 01/01/23 to 10/24/23 showed no data collection sources or activities utilized in the analysis of data in the agency's QAPI Program for calendar years 2021, 2022 and 01/01/23 to 10/24/23. On 10/25/23 at 1:00 a.m., Staff B stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; 2. Documentation showed no program improvement data or analysis of collected data for calendar years 2021, 2022 and 01/01/23 to 10/25/23.

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 for calendar years 2021, 2022 and 01/01/23 to 10/24/23 for all patients and employees. Findings: A review of QAPI for calendar years 2021, 2022 and 01/01/23 to 10/24/23 showed no PIP for calendar years 2021, 2022 and 01/01/23 to 10/24/23. On 10/04/23 at 11:30 a.m., Staff B stated the agency had no QAPI PIP records for calendar years 2021, 2022 and 01/01/23 to 10/24/23.

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 and was included in QAPI program activities for all patients and staff. Findings: A review of QAPI and Infection Control Program documents showed no infection control program surveillance monitoring and reporting as a part of QAPI program activities for calendar year 2021, 2022 and 01/01/23 to 10/24/23. On 10/25/23 at 1:00 p.m., Staff B stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; 2. Documentation showed no infection control program surveillance monitoring and reporting as a part of QAPI program activities for calendar years 2021, 2022 and 01/01/23 to 10/24/23.

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 services were provided as ordered on the POC for: 1. SN to conduct visit frequencies as ordered by the physicians for one (Patient #2) of seven patient; 2. OT evaluations were conducted for one (Patient #3) of seven patients; 3. SN to perform Libre continuous glucose monitor change every 14 days for one (Patient #3) of seven patients; 4. SN to perform venipuncture for laboratory test (Hgb A1C) for one (Patient #3) of seven patients; 5. SN to conduct assessment of patients pain levels and perform fingerstick blood sugar every visit and notify the physician of values outside of reporting parameters for two (Patients #5 and 6) of seven patients and; 6. SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight for one (Patients #7) of seven patients. Findings: Patient #2 A review of a POC dated 10/08/23 to 12/06/23, showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed during the weeks of 10/09/23 to 10/14/23 no SN visit was conducted (one visit ordered, no visit conducted [system generated SN visit note was blank]) and 10/15/23 to 10/21/23 conducted (one visit ordered, no visit conducted [system generated SN visit note was blank]). Documentation showed no patient refusal of visits, no physician notification of missed visits and no changes in orders. On 10/25/23 at 10:53 a.m., Staff A stated: 1. The SN visits were conducted but not documented by the SN and; 2. The agency had no proof that the SN visits for weeks of 10/09/23 to 10/14/23 and 10/15/23 to 10/21/23 were conducted. Patient #3 A review of a POC dated 09/22/23 to 11/20/23, showed orders for SN to change Libre continuous glucose monitor sensor every 14 days and perform venipuncture for laboratory test (Hgb A1C); and OT to evaluate for therapy needs week of 09/24/23. Documentation showed no change of the Libre continuous glucose monitor sensor every 14 days and no venipuncture for laboratory test (Hgb A1C) during conducted SN visits from 09/22/23 to 10/23/23. Documentation showed no OT evaluation from 09/22/23 to 10/23/23. Documentation showed no patient refusal of care and services, no physician notifications/communications and no changes in orders. Patient #5 A review of the POC dated 09/19/23 to 11/17/23 showed orders for SN to conduct assessment and monitoring of patient’s pain level and report levels greater than 6; and perform finger stick blood sugar and report random blood sugar levels greater than 200 every visit. Documentation showed no assessment and monitoring of the patient’s pain level and performed finger stick blood sugar during SN visits on 09/21/23, 09/26/23, 10/03/23, 10/10/23 and on 10/17/23. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain level and finger stick blood sugar during the SN visits, no physician notifications and no change in orders. On 10/25/23 at 11:15 a.m., Staff A stated the SN should have been conducted assessment and monitoring of the patient’s pain level and finger stick blood sugar every visit as ordered by the physician. Patient #6 A review of the POC dated 07/24/23 to 09/21/23 showed orders for SN to conduct assessment and monitoring of patient’s pain level and report levels greater than 5; and perform finger stick blood sugar and report random blood sugar levels greater than 200 every visit. Documentation showed no assessment and monitoring of the patient’s pain level and performed finger stick blood sugar during SN visits on 08/14/23, 08/21/23, 08/28/23, 09/04/23 and on 09/11/23. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain level and finger stick blood sugar during the SN visits, no physician notifications and no change in orders. On 10/25/23 at 11:20 a.m., Staff A stated the SN should have been conducted assessment and monitoring of the patient’s pain level and finger stick blood sugar every visit as ordered by the physician. Patient #7 A review of the POC dated 06/08/23 to 08/06/23 showed orders for SN to conduct assessment and monitoring of patient weight every visit and notify the physician of change in patient weight of 5 pound gain in 7 days. Documentation showed no assessment and monitoring of the patient’s weight was conducted during SN visits on 06/14/23, 06/21/23, 06/28/23 and on 07/05/23. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s weight during the SN visits, no physician notifications and no change in orders. On 10/25/23 at 11:25 a.m., Staff A stated the SN should have conducted assessment and monitoring of the patient’s weight every visit as ordered by the physician.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of nursing interventions performed by the SN for one (Patient #4) of seven patients. Findings: An agency policy titled Timely Submission of Patient Documentation stated documentation must be submitted within 24 hours after receipt and all visit reports must be submitted by the next scheduled workday, not exceeding three calendar days. Patient #4 A review of a POC dated 09/19/23 through 11/17/23 showed orders for SN to administer Vitamin B12 1000MCG IM every four weeks for Vitamin B12 deficiency. Documentation showed during SN visits dated 09/26/23, 10/03/23, 10/10/23, and 10/19/23 the SN administered Vitamin B12 IM during each visit (administered weekly, ordered every four weeks). Review of a physician’s order dated 10/11/2023 ordered a chest x-ray and to perform a venipuncture for laboratory tests CBC and CMP. Documentation showed no chest x-ray or venipuncture for laboratory tests were conducted. Documentation showed no patient refusal of x-ray or venipuncture for laboratory tests, no physician notification and no changes in orders. On 10/25/23 at 11:35 a.m., Staff A stated: The Vitamin B12 injection was administered during 09/26/23 SN visit; Should not have been documented as administered on 10/03/23, 10/10/23, and 10/19/23 SN visits; SN notes for 10/03/23, 10/10/23, and 10/19/23 had not been reviewed for approval prior to uploading into the clinical record and; The chest x-ray and the laboratory test venipuncture were conducted but their results were not documented or uploaded into the clinical record for patient #4.

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 three (Patients #3, 6 and #7) of seven patients. Findings: Patient #3 A review of the clinical record showed the patient was transferred to inpatient services on 09/24/23. Documentation showed no transfer summary and no summary of care was provided to the receiving inpatient service provider. Patient #6 A review of the clinical record showed the patient was transferred to inpatient services on 09/13/23. Documentation showed no transfer summary and no summary of care was provided to the receiving inpatient service provider. Patient #7 A review of the clinical record showed the patient was discharged to hospice services on 07/11/23. Documentation showed a discharge summary was auto-generated on 07/14/23. Documentation showed no summary of care was provided to the receiving hospice service provider. On 10/25/23 at 11:00 to 11:25 a.m., Staff A stated the agency did not provide a transfer summary to the hospital service providers for patients #3 and 6; and no discharge summary was provided to the hospice service provider for patient #7.