Every finding on record at United Partners Healthcare 2, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 08/26/24 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 08/26/24. An entrance conference was conducted with Staff A. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A and C. Deficiencies were cited as a result of the re-certification survey.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure supervisory aide visits were completed every 14 days for one (Patient #4) of seven patients. Patient #4 A plan of care dated 05/14/24 to 07/12/24 showed a home health aide frequency of two visits for one week and three visits per week for eight weeks. A review of the clinical record showed home health aide visits were completed on 05/15/24, 05/17/24, 05/20/24, 0522/24, 05/24/24, 05/27/24, 05/29/24, 05/31/24, 06/03/24, 06/05/24, 06/07/24, 06/10/24, 06/12/24, 06/14/24, 06/17/24, 06/19/24,06/21/24,06/24/24, 06/26/24, 06/28/24,07/01/24, 07/03/24, 07/05/24,07/08/24, 07/10/24 and 07/12/24. Documentation showed no supervisory aide visits from 05/14/24 to 07/12/24 (no completed supervisory aide visits for 60 days). On 08/26/24 at 2:30 pm., Staff A stated there were no supervisory aide visits completed for Patient #4.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical notes were complete for one (Patient #2) of seven patients. A review of the plan of care dates 05/22/24 to 07/20/24 showed a skilled nurse frequency of one visit per week for eight weeks. A review of the clinical record showed the following: A skilled nurse assessment dated 06/06/24 documented no assessment of the patient (note was blank) for the week of 06/02/24 to 06/08/24 (one of one documented visit). A skilled nurse assessment dated 06/13/24 documented no assessment of the patient (note was blank) for the week of 06/09/24 to 06/15/24 (one of one documented visit). A skilled nurse assessment dated 06/27/24 documented no assessment of the patient (note was blank) for the week of 06/23/24 to 06/29/24 (one of one documented visit). A skilled nurse assessment dated 07/11/24 documented no assessment of the patient (note was blank) for the week of 07/07/24 to 07/13/24 (one of one documented visit). On 08/26/24 at 2:35 am., Staff A stated the clinical notes for Patient #2 were incomplete.

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 discharge summary was provided for one (Patient #5) of seven patients. Patient #5 A review of the clinical record showed the patient was discharged from the agency on 05/14/24 to hospice care services. Documentation showed no discharge summary was provided to the primary care practitioner. On 08/26/24 at 2:40 pm., Staff A stated no discharge summary was sent to the primary care practitioner for Patient #5.