Every finding on record at Vahlberg Enterprises, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 03/05/24 to 03/06/24. 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 03/05/24 to 03/06/24. 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 and clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Deficiencies were cited as a result of the re-certification survey.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to review and revise an individualized Plan of Care for one (Patients #7) of seven patients. Patient #7 A review of the plan care dated 11/12/23 to 01/10/24 showed a skilled nurse frequency of one visit per day for one day, one visit per week for nine week and one visit per day for one day. A review of the clinical record showed the following: A skilled nurse missed visit note dated 11/21/23 for the week of 11/20/223 to 11/26/23 (no completed skilled nurse visits this week). A skilled nurse missed visit note dated 12/01/23 for the week of 11/27/23 to 12/03/23 (no completed skilled nurse visits this week). Skilled nurse missed visit notes dated 12/07/23 and 12/08/23 for the week of 12/04/23 to 12/10/23 (no skilled nurse visits this week). Skilled nurse missed visits notes dated 12/14/23 and 12/15/23 for the week of 12/11/23 to 12/17/23 (no skilled nurse visits this week). A skilled nurse missed visit note dated 12/21/23 for the week of 12/18/23 to 12/24/23 (no skilled nurse visits this week). No update were made to the plan of care to show the patients decreased need for skilled nursing services. On 03/06/24 at 3:30 pm, Staff A stated there were no updates made the plan of care to show the decreased need for skilled nursing services for Patient #7.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of alternative training required to meet the qualifications of a Home Health Aide for one (Staff F) of five employees reviewed. Staff F A review of personnel records showed certification as a Long Term Care Aide. Documentation showed no Home Health Aide certification and showed no completion of alternative training required to meet the qualifications of a Home Health Aide. On 03/06/24 at 1:50 pm., Staff C stated there was not completion of alternative training required to meet the qualifications of a Home Health Aide.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/23/21 though 03/24/21. 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 03/23/21 through 03/24/21. 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 and clinical issues. Findings were discussed during an informal exit conference with Staff A and by telephone with Staff B. Deficiencies were cited as a result of the Medicare re-certification survey:

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 home health aide services were provided as ordered for two (Patients #2 and 6) of seven patients. Findings: Patient #2 A review of the plan of care dated 08/27/20 to 10/25/20 showed home health aid visits ordered at a frequency of two visits per week for six weeks and one visit per week for one week. A review of the clinical record showed one home health aide visit completed on 09/02/20 during the week of 08/31/20 to 09/06/20 (one missing visit). Documentation showed no orders for home health aide frequency changes, no patient/caregiver refusal of visits and no missed visit notes. Patient #6 A review of the plan of care dated 01/11/21 to 03/11/21 showed home health aide visits ordered at a frequency of one visit per week for nine weeks. A review of the clinical record showed no home health aide visits for the week of 01/11/21 to 01/17/21 (one missing visit), no home health aide visits for the week of 01/18/21 to 01/24/21 (one missing visit) and no home health aide visits for the week of 01/25/21 to 01/31/21 (one missing visit). Documentation showed no orders for home health aide frequency changes, no patient/caregiver refusal and no missed visit notes. On 03/24/21 at 12:30 pm, Staff A stated the home health aide frequencies for Patient #2 and 6 were not met.