Every finding on record at Rice Home Health LLC

The Oklahoma Department of Health conducted an unannounced Emergency Preparedness Program survey at the agency on 01/30/24 to 01/31/24. A Standard deficiency was 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 document review and interview, the Agency failed to maintain an emergency preparedness plan that was reviewed and updated at least every 2 years based on facility-based and community-based risk assessment, utilizing an all-hazards approach.* A review of the Agency Emergency Preparedness documents revealed a hazard risk assessment was completed in 2020. Further review of the documents failed to provide evidence of an updated risk assessment for the years 2022 or 2023. On 01/31/24 at 11:45 AM, the Administrator stated the Agency failed to update the Agency hazard risk assessment as required.

The Oklahoma Department of Health conducted an unannounced Medicare re-certification survey at the agency on 01/30/24 to 01/31/24. An entrance conference was conducted with the Alternate Administrator. The survey process was explained. Questions were answered. The Alternate Administrator was identified as the contact person for administrative issues and the Supervising Nurse was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with the Administrator and Supervising Nurse. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: RN Registered Nurse SN Skilled Nurse POC Plan of Care SOC Start of Care

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 RN failed to conduct an initial assessment visit within 48 hours of referral or on the physician or allowed practitioner - ordered start of care date for one (#4) of eight (#1- #8) records reviewed. Patient #4 A review of the POC for Patient #4 for certification period 01/08/24 to 03/07/24 revealed a primary diagnosis of Hemiplegia, a referral date of 01/03/24 and a SOC date of 01/08/24. Further review of the record and the RN Initial SOC Visit note indicated Pt #4 was discharge from a facility on 01/05/24 but failed to provide documentation as to the reason why the Initial RN visit was not conducted within 48 hours of the patient's discharge. On 01/31/24 at 11:45 AM, the Administrator stated the SN staff failed to document the reason the Initial RN visit was not conducted within 48 hours of Patient#4 discharge.

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 Skilled Nurse staff failed to conduct 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 for three (#3, #4, and #6) of eight (#1- #8) records reviewed. Patient #3 A review of the POC for Patient #3 for certification period 01/02/24 to 03/01/24 revealed a primary diagnosis of Venous Insufficiency with orders for "RN to assess and evaluate for continued skilled care need, patient's ability to demonstrate necessary skills to self-manage disease processes including medication management..." Further review of the "Client Medication Report" failed to provide evidence the SN conducted a review of all medications the patient was currently taking 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. Patient #4 A review of the POC for Patient #4 for certification period 01/08/24 to 03/07/24 revealed a primary diagnosis of Hemiplegia with orders for "RN to assess and evaluate for continued skilled care need, patient's ability to demonstrate necessary skills to self-manage disease processes including medication management..." Further review of the "Client Medication Report" failed to provide evidence the SN conducted a review of all medications the patient was currently taking 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. Patient #6 A review of the POC for Patient #6 for certification period 07/27/23 to 10/06/23 revealed a primary diagnosis of Malignant Neoplasm of the Lung. The SOC Assessment and SN Visit Note of 07/27/23 indicated Pt #6 was currently using Oxygen continuously. Further review of the "Client Medication Report" failed to provide evidence the SN staff included Oxygen or conducted a review of current medications Pt #6 was currently taking to include Oxygen. On 01/31/24 at 11:45 AM, the Administrator stated the SN staff failed to conduct a review of all medications the patient was currently taking and failed to include Oxygen on the Client Medication Report and during a review of the medications for Patients #3, #4, and #6.

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 SN staff failed to provide services that are ordered by the physician or allowed practitioner as indicated in the plan of care for one (#5) of eight (#1 - #8) records reviewed. Patient #5 A review of the POC for Patient #5 for certification period 11/25/23 to 01/23/24 revealed a primary diagnosis of Surgical Aftercare for Circulatory System and secondary diagnosis of Hypertensive Heart Disease and Congestive Heart Failure. The POC included orders for the "SN to teach/instruct patient/caregiver measures to control hypertension including:...reaching and maintaining ideal weight" and to "Notify physician of: ...Weight greater than 175 lbs or less than 155 lbs." Further review of the SN visit notes failed to provide evidence the SN obtained or monitored Pt #5 weights for the weeks of 12/10/23, 12/17/23,12,24/23, 01/7/24 or 01/14/24 as required in order to notify the physician of any results outside the weight parameters. On 01/31/24 at 11:45 AM, the Administrator stated the SN staff failed to obtain weights as required for Patient#5.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the RN failed to conduct onsite supervisory visits to the patient's home no less frequently than every 14 days for three (#1, 6, and #8) of six (#1, #2, #4 and #6 - #8) records reviewed with orders for Home Health Aide services. Patient #1 Review of the POC for recertification periods 12/19/23 - 02/16/23 revealed a Primary Diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure with orders for Home Health Aide services 2 times a week for 9 weeks. Further review of RN documentation for Supervisory Aide Visits indicated onsite visits were conducted on 12/12/23 and 12/29/23 (3 days late) and on 01/11/24 and 01/26/24 (1 day late). Patient #6 Review of the POC for recertification periods 07/27/23 - 10/06/23 revealed a Primary Diagnosis of Malignant Neoplasm of the Lung with orders for Home Health Aide services 2 times a week for 8 weeks. Further review of RN documentation for Supervisory Aide Visits indicated and the first HHA visit was conducted on 07/27/23 and the first onsite Supervisory Aide visit was conducted on 08/23/23 (13 days late), on 09/04/23 and 10/05/23 (17 days late). Patient #8 Review of the POC for recertification periods 11/15/23 - 01/13/23 revealed a Primary Diagnosis of Alzheimer's Disease with orders for Home Health Aide services 2 times a week for 1 week and 3 times a week for 8 weeks. Further review of RN documentation for Supervisory Aide Visits indicated onsite visits were conducted on 11/10/23 and 11/30/23 (6 days late), on 12/28/23 and 01/12/23 (1 day late). On 01/31/23 at 1:45 PM, the Administrator stated the RN failed to conduct Supervisory Aide Visits at least every 14 days as required for Pt#1, Pt#6 and Pt#8.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the hospice on 03/03/21. 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 03/03/21. 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 administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Deficiencies were cited as a result of the Medicare re-certification survey: GLOSSARY: QAPI Quality Assessment and Performance Improvement PIP Performance Improvement Project

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. the skilled nurse and physical therapist assistant notified the physician of pulse readings outside of ordered parameters for one (Patient #2) of seven patients; 2. the skilled nurse and physical therapist assistant notified the physician of pain rating outside of the ordered parameters for one (Patient #2) of seven patients; 3. the skilled nurse notified the physician of weight measurements outside of ordered parameters for one (Patient #5) of seven patients and 4. the skilled nurse notified the physician of diastolic blood pressure reading outside of the ordered parameters for one (Patient #6) of seven patients. Findings: Patient # 2 A review of the plan of care dated 12/16/20 to 02/13/21 showed orders to notify the physician of a pulse reading less than 60 and to notify the physician of a pain rating greater than 7 on a 0-10 pain scale. A review of skilled nurse and physical therapy assistant assessments documented the following: A skilled nurse assessment dated 12/22/20 documented a pulse of 57 and pain rating of 8 with no notification to the physician. A skilled nurse assessment dated 12/29/20 documented a pulse of 55 and pain rating of 8 with no notification to the physician. A physical therapy assistant assessment dated 12/31/20 documented a pulse of 52 and pain rating of 10 with no notification to the physician. A skilled nurse assessment dated 01/05/21 documented a pulse of 57 with no notification to the physician. A physical therapy assistant assessment dated 01/06/21 documented a pain rating of 10 with no notification to the physician. A physical therapy assistant assessment dated 01/11/21 documented a pulse of 52 with no notification to the physician. A skilled nurse assessment dated 01/12/21 documented a pulse of 55 with no notification to the physician. A physical therapy assistant assessment dated 01/18/21 documented a pulse of 56 and pain rating of 10 with no notification to the physician. A physical therapy assistant assessment dated 01/27/21 documented a pain rating of 10 with no notification to the physician. A physical therapy assistant assessment dated 01/29/21 documented a pain rating of 10 with no notification to the physician. A skilled nurse assessment dated 02/01/21 documented a pulse of 57 with no notification to the physician. Patient #5 A review of the plan of care dated 12/08/20 to 02/05/21 showed orders to notify the physician of a weight measurement less than 155 pounds. A review of skilled nurse assessments documented the following: A skilled nurse assessment dated 12/11/20 documented a weight of 154 pounds with no notification to the physician. A skilled nurse assessment dated 12/18/20 documented a weight of 154 pounds with no notification to the physician. A skilled nurse assessment dated 12/31/20 documented a weight of 154 pounds with no notification to the physician. A skilled nurse assessment dated 01/06/21 documented a weight of 154 pounds with no notification to the physician. A skilled nurse assessment dated 01/15/21 documented a weight of 154 pounds with no notification to the physician. A skilled nurse assessment dated 01/22/21 documented a weight of 154 pounds with no notification to the physician. Patient #6 A review of the plan of care dated 09/10/20 to 11/05/20 showed orders to notify the physician of a diastolic blood pressure greater than 90. A review of skilled nurse assessments documented the following: A skilled nurse assessment dated 10/22/20 documented a diastolic blood pressure of 102 in the right arm and a diastolic blood pressure of 94 in the left arm with no notification to the physician. A skilled nurse assessment dated 11/05/20 documented a diastolic blood pressure of 94 with no notification to the physician. On 03/03/21 at 1:15 pm, Staff B stated: 1) the physician should have been notified of the pulse readings and pain ratings outside of parameters for Patient #2; 2) the physician should have been notified of the weight measurements below the ordered parameters for Patient #5 and 3) the physician should have been notified of the diastolic blood pressure readings above the ordered parameters for Patient #6.

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 122 patients and all employees. This failed practice had the potential to place the agency, all patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs for January 1, 2020 through March 03, 2021. On 03/03/21 at 1:30 pm, Staff A stated the agency had no documented PIP activities for 2020.