Every finding on record at Platinum Health Care of Oklahoma, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 07/16/25. 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), §485.542(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 current employee contact information for the agency for seven patients and 29 employees. Findings: A review of administrative records showed an Emergency Preparedness Communication Plan did not include contact information for seven of 29 current employees for the agency. On 07/16/25 at 2:30 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for all current employees of the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 07/16/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as a contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C and D. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary notice HHCOC home health change of care OASIS outcome and assessment information set POC Plan of Care 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 advance beneficiary or home health change of care notices prior to discharge from agency services were provided to two (Patients #1 and #7) of seven patients. Findings: Patient #1 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 07/03/25 for unknown reason. Patient #7 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 04/02/25 for unknown reason. On 07/16/25 at 2:20 p.m., Staff A stated: 1. There were no ABN of HHCOC notices in the clinical records for patients #1 and #7. 2. The clinical records for patients #1 and #7 showed no documented reason for discharge.

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 an initial assessment (evaluation) was conducted within 48 hours (2 days) of referral for one (Patient #3) of seven patients. Findings: Patient #3 A review of the clinical record showed the agency received referral information on 05/07/25 and the initial assessment (evaluation) occurred on 05/10/25 (3 days). Documentation showed no patient refusal of initial assessment (evaluation), no physician notification of a delay in initial assessment (evaluation) and no change in orders. On 07/16/25 at 2:02 p.m., Staff A stated the initial assessment (evaluation) should have been conducted by 05/09/25.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge oasis was completed by the agency for one (Patient #1) of seven patients. Findings: Patient #1 A review of a POC dated 05/07/25 to 07/05/25 showed a start of care date of 05/28/21. SN visits were conducted on 05/14/25, 05/30/25 and on 07/03/25. The SN visit notes showed no patient request for discharge and no discharge from agency services. At 10:10 a.m., Staff A stated: 1. The patient was discharged from agency services on 07/03/25. 2. The SN visit on 07/03/25 was scheduled as a routine SN visit and discharge OASIS documentation was not completed. 3. The clinical record showed no reason for discharge, no patient request for discharge and no physician notification of discharge.

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 #1) of seven patients. Findings: Patient #1 A review of the clinical record showed no discharge summary after discharge from agency services on 07/03/25. At 10:10 a.m., Staff A stated: 1. The patient was discharged from agency services on 07/03/25. 2. The SN visit on 07/03/25 was scheduled as a routine SN visit and discharge OASIS documentation was not completed. 3. The clinical record showed no reason for discharge, no patient request for discharge and no physician notification of discharge.

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 SN visits were conducted as ordered for two (Patients #6 and #7) of seven patients. Findings: Patient #1 A review of the POC dated 02/06/25 to 04/06/25 showed orders for SN visits once a week for six weeks, then one time every two weeks for two weeks. SN communication notes dated 03/01/25 and 03/04/25 showed SN missed visits due to “scheduling errors”. The SN communication notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/16/25 at 2:10 p.m., Staff A stated the SN should have provided SN visits as ordered on the POC. Patient #7 A review of the POC dated 02/02/25 to 04/02/25 showed orders for SN visits once a week for five weeks, then one time every two weeks for four weeks. SN communication notes dated 03/01/25 and 03/04/25 showed SN missed visits due to “scheduling errors”. The SN communication notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/16/25 at 2:20 p.m., Staff A stated the SN should have provided SN visits as ordered on the POC.

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 interviews, the agency failed to ensure: 1. A completed transfer summary was provided to the receiving service provider within 2 days of notification of in-patient admission for two (Patients #4 and #6) of seven patients. 2. A completed discharge summary was provided within 5 calendar days of discharge to the physician for one (Patient #7) of seven patients. Findings: Patient #4 A review of the clinical record showed an inpatient hospital transfer date of 12/06/24. The clinical record showed the agency was notified of the inpatient transfer on 12/06/24 and showed the transfer summary was provided to the inpatient facility on 12/11/24 (five days later). Patient #6 A review of the clinical record showed an inpatient hospital transfer date of 03/21/25. The clinical record showed the agency was notified of the inpatient transfer on 03/21/25 and showed the transfer summary was provided to the inpatient facility on 03/26/25 (five days later). Patient #7 A review of the clinical record showed a discharge date of 04/02/25. The clinical record showed the discharge summary was provided to the physician on 04/29/25 (27 days later). On 07/16/25 at 2:20 p.m., Staff A stated: 1. The receiving service provider should have received a copy of a transfer summary for patients #4 and #6 within 2 days of a transfer. 2. The physician should have received a copy of a discharge summary within 5 days of patient #7 discharge from agency services.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 08/23/22 to 08/24/22. 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 08/23/22 to 08/24/22. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical issues and Staff C and D were identified as the contact persons for administrative issues during the survey. Findings were discussed during an informal exit conference with Staff A, C and D. Standard level deficiencies were cited as a result of the survey. Glossary: POC plan of care OT Occupational Therapy PT Physical Therapy SN skilled nurse ST Speech Therapy

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure medication profiles were reviewed and updated for ordered medications for two (Patients #2 and #3) of 10 patients. Findings: Patient #2 A review of a POC dated 07/11/22 to 09/08/22 showed an order dated 08/11/22 for Cipro (an antibiotic) 250 milligrams once daily times seven days and fluconazole 100 milligrams once daily times seven days. Documentation showed no update to the medication profile and no review of the medications for allergy or drug interactions. On 08/24/22 at 11:34 a.m., Staff A stated the medication profile for patient #2 should have been updated with the addition of the medications and the medications should have been reviewed for allergies and drug interactions. Patient #3 A review of a POC dated 08/03/22 to 10/01/22 showed an order dated 08/23/22 for Toujeo (an anti-diabetic agent) increased to 40 units once daily. Documentation showed the medication profile was not updated from Toujeo 30 units once daily dose to the ordered increased dose of 40 units once daily. On 08/24/22 at 9:30 a.m., Staff A stated the medication profile for patient #3 should have been updated to reflect the ordered increased dose of Toujeo 40 units once daily.

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 the individualized patient POC included recurring urinary catheter change due dates were documented for one (Patient #2) of 10 patients. Findings: Patient #2 A review of the plan of care dated 07/11/22 to 09/08/22 documented a diagnosis of urinary retention. POC orders instructed SN to change indwelling Foley catheter every month. POC documentation showed no treatment date the indwelling Foley catheter change was last changed or due. On 08/24/22 at 11:34 a.m., Staff A stated recurring urinary catheter change due dates should have been documented in the individualized POC for patient #2.

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 clinician to: 1. Conduct OT visit frequency as ordered by the physician for one (Patient #2) of 10 patients; 2. Conduct SN visit frequency as ordered by the physician for one (Patient #6) of 10 patients and; 3. Conduct PT visit frequency as ordered by the physician for one (Patient #10) of 10 patients. Findings: Patient #2 A review of the plan of care dated 07/11/22 to 09/08/22 showed an OT visit frequency of one time a week for nine weeks. Documentation showed during the week of 07/11/22 to 07/16/22 no OT visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification of a missed visit and no changes in orders. On 08/24/22 at 11:34 a.m., Staff A stated no OT visit was conducted 07/11/22 to 07/16/22 on patient #2. Patient #6 A review of a plan of care dated 07/22/22 to 09/19/22 showed a SN visit frequency of one time a week for nine weeks. Documentation showed during the week of 07/22/22 to 07/23/22 no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification of a missed visit and no changes in orders. On 08/24/22 at 11:42 a.m., Staff A stated no SN visit was conducted 07/22/22 to 07/23/22 on patient #6. Patient #10 A review of the plan of care dated 04/26/22 to 06/24/22 showed a PT visit frequency of one time a week for one weeks, two times a week for four weeks, then one time a week for four weeks. Documentation showed during the week of 05/01/22 to 05/07/22 no PT visit were conducted (two visits ordered, no visits conducted) and during the week of 05/08/22 to 05/14/22 no PT visit were conducted (two visits ordered, no visits conducted). Documentation showed the visits were not conducted due to “no patient information”, and showed no physician notification of the missed visits and no changes in orders. On 08/24/22 at 12:00 p.m., Staff A stated the PT visits for patient #10 should have been conducted and the PTA should have notified the agency and the physician that the visits had been missed.

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 visit note documentation was completed for five (Patients #1, 4, 5, 6 and #7) of 10 patients. Findings: Patient #1 A review of a plan of care dated 08/07/22 to 10/05/22 showed a SN visit frequency of three times a week for one week, then one time a week for one week. Documentation showed SN visit conducted on 07/18/22 was completed/submitted on 08/14/22 (27 days after the visit was conducted) and SN visit conducted on 08/10/22 was completed/submitted on 08/13/22 (3 days after the visit was conducted). Documentation showed no patient or caregiver refusal of the SN visits, no physician notification and no changes in orders. On 08/24/22 at 11:29 a.m., Staff A stated the visit notes for patient #1 should have been completed/submitted to the patient’s clinical record within 2 days from the date of the visit. Patient #4 A review of a plan of care dated 06/17/22 to 08/15/22 showed a SN visit frequency of one time a week for nine weeks. Documentation showed SN visit conducted on 06/23/22 was completed/submitted on 07/11/22 (18 days after the visit was conducted) and SN visit conducted on 08/08/22 was completed/submitted on 08/22/22 (14 days after the visit was conducted). Documentation showed no patient or caregiver refusal of the SN visits, no physician notification and no changes in orders. On 08/24/22 at 11:38 a.m., Staff A stated the visit notes for patient #4 should have been completed/submitted to the patient’s clinical record within 2 days from the date of the visit. Patient #5 A review of a plan of care dated 08/03/22 to 10/01/22 showed a SN visit frequency of one time a week for eight weeks. Documentation showed SN visit conducted on 07/01/22 (conducted during previous certification period) was completed / submitted on 08/20/22 (50 days after the visit was conducted) and SN visit conducted on 08/04/22 was completed/submitted on 08/12/22 (8 days after the visit was conducted). Documentation showed no patient or caregiver refusal of the SN visits, no physician notification and no changes in orders. On 08/24/22 at 11:40 a.m., Staff A stated the visit notes for patient #5 should have been completed/submitted to the patient’s clinical record within 2 days from the date of the visit. Patient #6 A review of a plan of care dated 07/22/22 to 09/19/22 showed a SN visit frequency of one time a week for nine weeks. Documentation showed SN visit conducted on 07/18/22 (conducted during previous certification period) was completed/ submitted on 07/24/22 (6 days after the visit was conducted), SN visit conducted on 07/25/22 was completed/submitted on 08/21/22 (26 days after the visit was conducted) and SN visit conducted on 08/06/22 was completed/submitted on 08/21/22 (15 days after the visit was conducted). Documentation showed no patient or caregiver refusal of the SN visits, no physician notification and no changes in orders. On 08/24/22 at 11:42 a.m., Staff A stated the visit notes for patient #6 should have been completed/submitted to the patient’s clinical record within 2 days from the date of the visit. Patient #7 A review of a plan of care dated 08/04/22 to 10/02/22 showed a SN visit frequency of one times a week for one week, then one time a week every other week for six weeks. Documentation showed SN visit conducted on 08/07/22 had no documentation of the visit completed/submitted as of 08/24/22 (18+ days after the visit was conducted). Documentation showed no patient or caregiver refusal of the SN visits, no physician notification and no changes in orders. On 08/24/22 at 11:45 a.m., Staff A stated the visit note for patient #7 should have been completed/submitted to the patient’s clinical record within 2 days from the date 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 appointment of the administrator for the agency effecting all patients and staff. Findings: On 08/23/22 at 10:28 a.m., Staff A stated the administrator license posted at the agency was for the former administrator (name withheld) who left the agency in February 2022. Staff A identified the current administrator as (name withheld). Additional administrative records were requested. A review of a change of information form dated 05/17/22 to OSDH showed documentation the administrator for the agency was changed effective 04/01/22. A review of administrative records for 03/01/22 through 08/24/22 showed no appointment of the administrator by the governing body for the agency. On 08/24/22 at 10:00 a.m., Staff C stated the governing body minutes for 03/01/22 through 08/24/22 were provided in their entirety and did not document a designation of the administrator for 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 transfer/discharge summary was provided to the receiving service provider for three (Patient #8, 9 and #10) of 10 patients. Findings: Patient #8 A review of the clinical record documented transfer from the agency on 07/10/22 to in-patient hospital services with subsequent discharge from agency services on 08/06/22. Documentation showed no transfer/discharge summary was provided to the in-patient hospital service provider at the time of transfer or discharge from agency services. On 08/24/22 at 11:50 a.m., Staff A stated no transfer/discharge summary was provided the in-patient hospital service provider for patient #8. Patient #9 A review of the clinical record documented transfer from the agency on 06/03/22 to in-patient hospital services with subsequent discharge from agency services to hospice service provider on 06/10/22. Documentation showed no transfer summary was provided to in-patient hospital service provider at the time of transfer from the agency and no discharge summary was provided to the hospice service provider at the time of discharge from agency services. On 08/24/22 at 11:55 a.m., Staff A stated no transfer or discharge summary was provided to the in-patient service provider at the time of transfer and no discharge summary was provided to the hospice service provider at the time of discharge for patient #9. Patient #10 A review of the clinical record documented transfer from the agency on 06/05/22 to in-patient hospital services with subsequent discharge from agency services on 07/18/22. Documentation showed no transfer summary was provided to in-patient hospital service provider at the time of transfer from the agency and no discharge summary was provided at the time of discharge from agency services. On 08/24/22 at 12:00 p.m., Staff A stated no transfer or discharge summary was provided to the in-patient service provider for patient #10.