Every finding on record at Truheart Home Health LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 12/29/25 to 12/31/25. 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 risk assessment (All Hazards Risk Assessment) was developed and implemented for the agency for 143 patients and 13 employees. Findings: A review of emergency preparedness records showed a community-based risk assessment (All Hazards Risk Assessment) that identified another agency (name withheld). A request for additional emergency preparedness records yielded no results. On 12/29/25 at 2:00 p.m., Staff A stated the agency did not have an AHRA which identified the agency.

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 143 patients and 13 employees. Findings: A review of emergency preparedness records showed an Emergency Preparedness Communication Plan which: 1. Included former employee contact information. 2. Did not contain some current employee contact information for the agency. On 12/29/25 at 2:00 p.m., Staff A stated the emergency preparedness communication plan employee roster was not updated to include contact information for current employees of the agency.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness disaster plan had a qualifying activation event, table-top exercise, facility drill or community drill in calendar year 2024 for 143 patients and 13 employees. Findings: A review of emergency preparedness records showed no emergency preparedness disaster plan activation events, table-top exercise, facility drill or community drill in calendar year 2024 and showed no after-action response to a plan activation event on 01/10/25. A request for additional emergency preparedness records yielded no results. On 12/29/25 at 2:00 p.m., Staff A stated: 1. All emergency preparedness program documentation was provided. 2. The agency had no activity for calendar year 2024. 3. The Emergency preparedness program activation event on 01/10/25 had no after-action response follow up.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency from 12/29/25 to 12/31/25. 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 and clinical issues. Findings were discussed during an informal exit conference with Staff A. Standard level deficiencies were cited as a result of the survey. Glossary: OASIS outcome and assessment information set PIP performance improvement project POC Plan of Care QAPI Quality Assessment and Performance Improvement SN skilled nurse 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 agency failed to ensure an initial evaluation/SOC assessment was conducted within 48 hours of referral for two (Patients #1 and #4) of nine patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 08/21/25 and the initial evaluation/SOC assessment occurred on 08/25/25 (4 days). The clinical record showed no patient refusal of initial evaluation/SOC assessment, no physician notification of a delay in SOC and no change in orders prior to 08/25/25. On 12/31/25 at 9:05 a.m., Staff A stated the initial evaluation/SOC assessment was not conducted within 2 days of referral and the order to delay the SOC was not obtained until 08/25/25. Patient #4 A review of the clinical record showed the agency received referral information on 10/31/25 and the initial evaluation/SOC assessment occurred on 11/04/25 (4 days). The clinical record showed no patient refusal of initial evaluation/SOC assessment, no physician notification of a delay in SOC and no change in orders prior to 11/04/25. On 12/31/25 at 9:10 a.m., Staff A stated the initial evaluation/SOC assessment was not conducted within 2 days of referral and the order to delay the SOC was not obtained until 11/04/25.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded 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 orders to discontinue a skilled intervention was a part of the patient’s POC for one (Patient #5) of nine patients. Findings: Patient #5 A review of the POC dated 11/15/25 to 01/13/26 showed orders for SN to perform Foley catheter change intervention every 4-weeks, next change due week of 11/30/25. A review of a SN visit note dated 12/02/25 stated the Foley catheter was removed during a physician’s office appointment on 11/26/25. The clinical record showed no SN Foley catheter change intervention and no physician notification for changes in orders. On 12/31/25 at 9:20 a.m., Staff A stated the POC had no order to discontinue every 4-week Foley catheter changes.

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 quality indicator data as a part of its QAPI program for all patients and employees. Findings: A request for QAPI records for calendar year 2024 yielded no results. A review of QAPI records for 01/01/25 to 12/30/25 showed no quality indicator data collection sources from OASIS reporting were utilized in the analysis of data in the agency's QAPI Program. On 12/30/25 at 8:40 a.m., Staff A stated: 1. All QAPI program records for the agency were provided and the agency had no QAPI records for calendar year 2024. 2. QAPI records for 2025 showed no analysis of quality indicator data sources.

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 interviews, the agency failed to ensure performance improvement project identification and activity for the agency in calendar year 2024 and 01/01/25 to 12/30/25 for all patients and employees. Findings: QAPI records for calendar year 2024 yielded no results. A review of QAPI Program records showed no performance improvement project identification and activity from 01/01/25 to 12/30/25. On 12/30/25 at 8:40 a.m., Staff A stated the agency had no QAPI PIP in calendar year 2024 and in 2025.

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 conducted visits as ordered for two (Patients #2 and #8) of nine patients. Findings: Patient #2 A review of the POC dated 12/02/25 to 01/30/26 showed orders for a SN visit frequency of one time a week for nine weeks. A review of the clinical record showed during the weeks of: · 12/07/25 to 12/13/25, a missed visit occurred on 12/10/25 (one visit ordered, no visit conducted) and showed no patient refusal to reschedule the visit, no physician notification of the missed visit and no changes in orders. · 12/21/25 to 12/27/25, a missed visit occurred on 12/23/25 (one visit ordered, no visit conducted) and showed no patient refusal to reschedule the visit, no physician notification of the missed visit and no changes in orders. On 12/31/25 at 9:10 a.m., Staff A stated the nurse did not attempt to make up the missed visits and did not notify the physician of the missed visits. Patient #8 A review of the POC dated 11/23/25 to 01/21/26 showed orders for a SN visit frequency of one time a week for nine weeks. A review of the clinical record showed that during the week of 12/21/25 to 12/27/25, a missed visit occurred on 12/23/25 (one visit ordered, no visit conducted) and showed no patient refusal to reschedule the visit, no physician notification of the missed visit and no changes in orders. On 12/31/25 at 9:35 a.m., Staff A stated the nurse did not attempt to make up the missed visit and did not notify the physician of the missed visits.

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 clinical visit note documentation was complete for two (Patients #4 and #6) of nine patients. Findings: Patient #4 A review of the POC dated 11/04/25 to 01/02/26 showed orders for SN to assess and monitor health conditions and perform medication administration of Trulicity 0.75 micrograms subcutaneous injection weekly. SN visit notes dated: · 11/12/25 showed no injection site or patient response to the injection. · 11/19/25 showed no injection site or patient response to the injection. · 12/17/25 showed no name of the medication that was administered. · 12/24/25 showed no dose of the medication that was administered. On 12/31/25 at 9:12 a.m., Staff A stated the SN clinical visit notes did not document medication administration detail. Patient #6 A review of the POC dated 11/10/25 to 01/08/26 showed orders for SN to assess and monitor health conditions and perform medication administration of Dupixent 300 milligrams 2-milliliters subcutaneous injection every 2-weeks and Repatha 420 milligrams subcutaneous injection every month. SN visit notes dated 11/21/25 showed no injection sites or patient response to either injection. On 12/31/25 at 9:12 a.m., Staff A stated the SN clinical visit note did not document medication administration detail.

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 completed transfer/discharge summaries were provided to receiving service providers for two (Patients #6 and #7) of nine patients. Findings: Patient #6 A review of the clinical record showed transfer from the agency on 11/28/25 to inpatient hospital services. The clinical record showed no transfer summary was provided to the receiving inpatient hospital service provider. Additional review of the clinical record showed discharge to hospice services on 12/10/25. The clinical record showed no discharge summary was provided to the receiving hospice provider or to the ordering physician. Patient #7 A review of the clinical record showed transfer from the agency on 11/06/25 to inpatient hospital services. The clinical record showed no transfer summary was provided to the receiving inpatient hospital provider or to the ordering physician. On 12/31/25 at 9:30 a.m., Staff A stated neither transfer nor discharge summaries were sent to the receiving providers for patients #6 and #7.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/02/22 to 11/03/22. 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 11/02/22 to 11/03/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A, B and Staff C were identified as the contact persons for administrative and clinical 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 Medicare re-certification survey. Glossary: OT occupational therapy PT physical therapy QAPI Quality Assessment Performance Improvement SN skilled nurse

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 reviews and interview, the agency failed to ensure a transfer/discharge summary was completed at the time of patient transfer/discharge for one (Patient #6) of seven patients. Findings: Patient #6 A review of the clinical record showed the patient was transferred/discharged from the agency on 08/16/22 to hospice provider services. Documentation showed no transfer or discharge summary was completed. On 11/03/22 at 9:40 a.m., Staff B stated the clinical record showed no transfer or discharge summary of care for patient #6.

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’s included: 1. An identified site of a wound for wound care for one (Patient #6) of seven patients and; 2. Pain reporting parameter for one (Patient #7) of seven patients. Findings: Patient #6 A review of the plan of care dated 06/29/22 to 08/27/22 documented a principal diagnosis of lower extremity ulcer and POC orders for SN to instruct and perform wound care as follows: cleanse wound with Hibiclens, saline, apply petroleum wound gel, to be done daily. A review of the POC showed no documentation of specific extremity wound site location. On 11/03/22 at 9:37 a.m., Staff B stated the POC for patient #6 should document specific extremity wound site location to receive wound site care. Patient #7 A review of the plan of care dated 07/24/22 to 09/21/22 documented a principal diagnosis of hypertensive heart and kidney disease with heart failure. Documentation showed SN to assess pain levels and medication effectiveness and instruct on pain relief measures. Documentation showed no identification of pain level associated with pain and no pain reporting parameter for physician notification of the patient’s pain levels exceeding medication and pain relief measures effectiveness. On 11/03/22 at 9:40 a.m., Staff B stated the individualized POC for patient #7 should have documented a pain reporting parameter.

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 care was coordinated between the agency and physician for two (Patients #4 and #5) of seven patients. Findings: Patient #4 A review of a plan of care dated 09/22/22 to 11/20/22 documented a primary diagnosis of spinal stenosis and showed a physician’s order for occupational therapy evaluation (documentation showed no order for treatment in addition to the evaluation). Documentation showed an occupational therapy evaluation dated 09/27/22 with OT therapy visits conducted on 10/03/22, 10/09/22 and on 10/18/22. Documentation showed no coordination of care with the physician and no order for the occupational therapy treatment frequency of one time a week for four weeks. Documentation showed an occupational therapy re-evaluation dated 10/18/22 with OT therapy visits conducted on 10/24/22 and on 10/28/22. Documentation showed no coordination of care with the physician and no order for the occupational therapy treatment extension frequency of two times a week for two weeks, then one times a week for two weeks. On 11/03/22 at 09:22 a.m., Staff B stated the OT should have contacted the physician to coordinate the care and communicate the treatment frequency of OT services with the physician for patient #4. Patient #5 A review of a plan of care dated 09/20/22 to 11/18/22 documented a primary diagnosis of Diabetes Mellitus Type II with hypoglycemia and showed a physician reporting parameter of blood sugar less than 60 and SN to perform finger stick blood sugar during visit if finger stick blood sugar has not been performed or if patient reports signs and symptoms of hypo/hyperglycemia. A review of SN visit notes dated 09/29/22, 10/06/22, 10/13/22, 10/20/22 and on 10/27/22 documented the patient reported she was unable to perform her own finger stick blood sugar, blood sugar levels were in the 20’s to 40’s and had experienced a weight loss of 20 to 30 pounds in 3 weeks. Documentation showed no physician coordination of care communications as follow up to the patient’s reported changes in ability to perform finger stick blood sugars, low blood sugar levels and weight loss; and showed no changes in orders. On 11/03/22 at 9:32 a.m., Staff B stated the physician for patient #5 should have been notified the patient had reported she was unable to perform her own finger stick blood sugar, blood sugar levels were in the 20’s to 40’s and had experienced a weight loss of 20 to 30 pounds during SN visits conducted on 09/29/22, 10/06/22, 10/13/22, 10/20/22 and on 10/27/22.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees. Findings: A review of administrative records showed no ongoing QAPI program activities to improve the care, services, and operations of the agency for calendar year 2020. On 11/03/22 at 1:30 p.m., Staff C stated the agency had no QAPI documentation which showed QAPI program activities for calendar year 2020.

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 #1, 6 and #7) of seven patients. Findings: Patient #1 A review of the clinical record documented transfer from the agency on 10/19/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. Patient #6 A review of the clinical record documented discharge from the agency on 08/16/22 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #7 A review of the clinical record documented discharge from the agency on 09/12/22 to in-patient hospital provider services. Documentation showed no discharge summary was provided to the in-patient hospital service provider. On 11/03/22 at 9:50 a.m., Staff B stated no transfer or discharge summary was sent to the receiving service providers for patients #1, 6 and #7.