Every finding on record at Ponca City Home Care Services, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/18/26 to 03/19/26. 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 survey at the agency 03/18/26 to 03/19/26. 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 administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D, E, F and G. Standard level deficiencies were cited as a result of the survey. Glossary: ABN advance beneficiary notice HHA Home Health Agency POC Plan of Care PT physical therapy SN skilled nurse ST speech therapy

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an advance beneficiary notice was provided to one (Patient #11) of 11 patients. Findings: An agency policy titled, "Advance Beneficiary Notice," showed requirements for the agency to issue an ABN at termination of services. The policy stated a beneficiary must be notified far enough in advance of the care change to pursue alternatives to continue receiving care and the agency must explain the notice and its content prior to the beneficiary signing it. Patient #11 A review of the clinical record showed no advance notice of discharge, prior to discharge from the agency on 01/06/26 for cause. The clinical record showed no documentation of behaviors or communication of care notes related to discharge for cause. On 03/19/26 at 12:15 p.m., Staff A stated there was no ABN given to the patient prior to being discharged from the agency.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: document problems and behaviors that impeded the HHA from providing care and servicesEducate the patient on potential health outcomes from discontinued HHA care and services and Inform the physician of the patient’s imminent discharge from the HHA for cause for one (Patient #11) of 11 patients. Findings: An agency policy titled, "Patient Discharge/Transfer Process," stated "... In the event of a discharge for cause the agency will advise the patient and physician of possible discharge; attempt to resolve problems presented by patient behavior; provide contact information for other agencies and ensure issues are documented in the medical record." Patient #11 A review of a POC for 12/17/25 to 02/14/26 showed a SN visit frequency of one time a week for eight weeks and orders for SN to assess and teach medication management, assess and conduct interventions to maintain a peripherally inserted central catheter for the treatment of lung cancer. A review of visit notes dated 12/23/25, 12/30/25 and on 01/06/26 showed no patient behaviors and identified no problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services, no communication or education attempts to the patient for potential health outcomes resulting from discontinued HHA care and services, no physician notification of the patient's behaviors that impeded the HHA from providing care and services, and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 01/06/26. On 03/19/26 at 12:15 p.m., Staff A stated the clinical record showed no documentation of: 1. Problems encountered by the HHA related to behaviors that caused the agency to be unable to provide care and services. 2. Patient education of potential outcomes from discontinued agency care and services. 3. Physician notification of the patient’s discharge from the agency.

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 ST conducted an evaluation as ordered for one (Patient #7) of 11 patients. Findings: Patient #7 A review of the POC dated 01/27/26 to 03/27/26 showed orders for speech therapy to evaluate during the week of 02/01/26. A review of the clinical record showed during the week of 02/01/26 to 02/07/26 no ST evaluation was conducted (one visit ordered, no visit conducted). The clinical record showed an ST evaluation was conducted on 02/20/26 and showed no missed visits, no patient refusal of visits, no physician notifications and no change in orders prior to the evaluation date of 02/20/26. On 03/19/26 at 12:00 p.m., Staff A stated the ST did not conduct the evaluation visit as ordered.

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 reviews and interviews, the agency failed to ensure visit note documentation was completed for one (Patient #5) of 11 patients. Findings: An agency policy titled, Wound Assessment Documentation states all wounds will be assessed with documentation. Document exact wound care performed following physician orders. Patient #5 A review of the POC dated 01/05/26 to 03/05/26 showed orders for SN to conduct venous stasis wound site care to bilateral lower extremities of cleanse with Vasche wound cleanser, apply Aquaphor, sprinkle with nystatin powder, and apply Urgotel alginate silver with a two-layer compression wrap dressing every visit. A review of SN visit notes conducted on 01/05/26, 01/07/26, 01/09/26, 01/12/26, 01/14/26, 01/27/26 and 02/03/26 showed no wound site care that was conducted during the visits and documented “wound care completed per order” on each SN visit note. On 03/19/26 at 11:36 p.m., Staff B stated the nurses should have documented the wound care that was performed on the patient in every visit note.

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 a transfer summary or discharge summary was provided to a receiving service provider for three (Patients #6, 9 and #10) of 11 patients. Findings: An agency policy titled, "Patient Discharge/Transfer process" stated a transfer summary was sent to the primary care physician and the facility to which the patient is transferred to within 2 business days of becoming aware of an unplanned transfer of care. Patient #6 A review of the clinical record showed transfer to in-patient services on 02/26/26 and showed a transfer summary of care was provided to the in-patient provider on 03/02/26 (four days later). A review of the clinical record showed the physician was provided with a transfer summary of care on 03/02/26 (four days later) after the transfer of care. On 03/19/26 at 11:45 a.m., Staff A stated the transfer summary of care was not sent to the in-patient facility and the physician until four days later. Patient #9 A review of the clinical record showed transfer to in-patient services on 12/19/25 and showed a transfer summary of care was provided to the in-patient provider on 12/22/25 (three days later). A review of the clinical record showed the physician was provided with a transfer summary of care on 12/24/25 (five days later) after the transfer of care. On 03/19/26 at 12:05 p.m., Staff A stated the transfer summary of care was not sent to the in-patient facility three days later and the physician until five days later. Patient #10 A review of the clinical record showed transfer to in-patient services on 01/15/26 and showed no transfer summary of care was provided to the in-patient provider. On 03/19/26 at 12:10 p.m., Staff A stated the transfer summary of care was not sent to the in-patient facility.

The Oklahoma State Department of Health conducted an unannounced Emergency Preparedness Program Survey at the agency on 11/28/22 to 11/29/22. 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 11/28/22 to 11/29/22. An entrance conference was conducted with Admin1 and RN1. The survey process was explained. Questions were answered. Admin1 was identified as the contact person for administrative issues and the contact person for clinical issues. Findings were discussed during an informal exit conference with Admin1, RN1 and administrative team members. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: Admin Administrator RN Registered Nurse SN Skilled Nurse POC Plan of Care

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, SN staff failed to provide an individualized POC to include patient-specific interventions for two (#1 and #4) of two (#1 and #4) records reviewed with orders for wound care services. Patient #1 A record review for Patient #1 certification period 10/31/22 to 12/29/22 revealed a primary diagnosis of Hypertension and Chronic Kidney Disease and secondary diagnosis of Congestive Heart Failure and Type II Diabetes Mellitus. Documentation indicated Patient #1 had a peritoneal catheter in place that required weekly draining and catheter site care by the SN staff as well as two lower extremity wounds on the Left Heel and the Right Great Toe. The POC included a wound care order that stated "...SN to remove old dressing if present, cleanse with wound cleanser. pat dry, apply silvergel. Cover with adhesive foam dressing. Weekly". This order failed to include the patient-specific location of the wound to be addressed by the SN staff. Patient #4 A review of the POC for Patient #4 for certification period 10/31/22 to 12/29/22 revealed a primary diagnosis of Non ST Elevation Myocardial Infarction. The POC included an order for "SN to remove old dressing if present, cleanse with betadine. Apply dry gauze to open area. Cover with tape. As needed for soiling". This order failed to include the patient-specific location of the wound to be addressed by the SN staff. SN documentation on the "Wound Record" for Left Inguinal wound indicated the SN did not complete wound care on 11/07/22 and 11/16/22 as the Caregiver completed wound care. Further record review failed to provide evidence of an order specific to the Caregiver education or approval to provide wound care or dressing changes. During an interview on 11/29/22 at 1:00 PM, Admin1 stated the SN staff failed to provide patient-specific wound care orders for Patient #1 and #4.

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, SN staff failed to provide services as ordered by the physician in the POC for one (#5) of seven (#1 - #7) records reviewed. Patient #5 A review of the POC for Patient #5 for certification period 11/03/22 to 01/01/23 revealed a primary diagnosis of Malignant Neoplasm of Lung and comorbid condition of Failure to Thrive. The POC contained orders for SN visits 1 time a week for 7 weeks and for the "SN to obtain weights every visit and notify RN/MD of weight gain or loss of 3 lbs. within 7 days". Further review of SN Visit Notes failed to provide evidence the SN assessed or obtained weights for visits conducted on 11/09/22, 11/16/22 and 11/23/22 as ordered. During an interview on 11/29/22 at 1:00 PM, Admin1 stated the SN failed to obtain weights as ordered by the physician on the POC for Patient #5.