Every finding on record at Phc Health, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/03/23 to 10/05/23. No deficiencies were cited as a result of the Medicare Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/03/23 to 10/05/23. An entrance conference was conducted with Staff A, B, C and D. The survey process was explained. Questions were answered. Staff B and C were identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A, B, C, D and E. Standard level deficiencies were cited as a result of the Medicare re-certification survey.

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: 1. develop an individualized plan of care to include weight parameters and monitoring of weight for one (Patient #2) of seventeen patients, and 2. develop an individualized plan of care outlining the assessment and monitoring of wounds for two (Patient #5 and 6) of seventeen patients. Patient #2 A plan of care dated 07/18/23 to 09/15/23 showed a primary diagnosis of hypertensive heart with chronic kidney disease. A review of the plan of care showed no orders or instruction for parameters of weight loss or weight gain and for the monitoring of the patient's weight. Patient #5 A plan of care dated 06/24/23 to 08/22/23 showed a primary diagnosis of pressure ulcer of sacral region, stage IV. A review of the plan of care showed no orders or instructions outlining the assessment and monitoring of the pressure ulcer. Patient #6 A plan of care dated 09/07/23 to 11/05/23 showed a primary diagnosis of encounter for change or removal of nonsurgical wound dressing with secondary diagnoses of stage IV pressures ulcer to right and left buttocks. A review of the plan of care showed no orders or instructions outlining the assessment and monitoring the nonsurgical wound and pressure ulcers. On 10/05/23 at 1:50 pm, Staff B stated: 1. the plan of care for Patient #2 failed to include wight parameters and monitoring of weight for Patient #2. and 2. the plan of care for Patients #5 and 6 failed to include orders for the assessment and monitoring of wounds.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. skilled nurse services were provided as ordered for one (Patient #1) of seventeen patients and 2. speech therapy services were provided as ordered for one (Patient #2) of seventeen patients. Patient #1 A review of the plan of care dated 06/17/23 to 08/15/23 showed a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical record showed no skilled nurse visit completed for the week of 08/06/23 to 08/12/23 (one missing visit). Documentation showed no orders for skilled nurse frequency changes, no patient/caregiver refusal of visits and no missed visit notes. Patient #2 A review of the plan of care dated 07/18/23 to 09/15/23 showed a physician order for speech therapy to evaluate and treat. A review of the clinical record showed no speech therapy evaluation completed. On 09/05/23 at 2:05 pm, Staff B stated: 1. skilled nurse services were not completed as ordered for Patient #1 and; 2. the speech therapy evaluation was not completed for Patient #2.