Choice Health at Home - Tulsa

“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 seven patients and 29 employees. Findings: A review of administrative records showed an Emergency Preparedness Communication Plan did not include contact information for seven of 29 current employees for the agency. On 07/16/25 at 2:30 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for all current employees of the agency.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a discharge summary for one (Patient #1) of seven patients. Findings: Patient #1 A review of the clinical record showed no discharge summary after discharge from agency services on 07/03/25. At 10:10 a.m., Staff A stated: 1. The patient was discharged from agency services on 07/03/25. 2. The SN visit on 07/03/25 was scheduled as a routine SN visit and discharge OASIS documentation was not completed. 3. The clinical record showed no reason for discharge, no patient request for discharge and no physician notification of discharge.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary or home health change of care notices prior to discharge from agency services were provided to two (Patients #1 and #7) of seven patients. Findings: Patient #1 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 07/03/25 for unknown reason. Patient #7 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 04/02/25 for unknown reason. On 07/16/25 at 2:20 p.m., Staff A stated: 1. There were no ABN of HHCOC notices in the clinical records for patients #1 and #7. 2. The clinical records for patients #1 and #7 showed no documented reason for discharge.”

“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 assessment (evaluation) was conducted within 48 hours (2 days) of referral for one (Patient #3) of seven patients. Findings: Patient #3 A review of the clinical record showed the agency received referral information on 05/07/25 and the initial assessment (evaluation) occurred on 05/10/25 (3 days). Documentation showed no patient refusal of initial assessment (evaluation), no physician notification of a delay in initial assessment (evaluation) and no change in orders. On 07/16/25 at 2:02 p.m., Staff A stated the initial assessment (evaluation) should have been conducted by 05/09/25.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge oasis was completed by the agency for one (Patient #1) of seven patients. Findings: Patient #1 A review of a POC dated 05/07/25 to 07/05/25 showed a start of care date of 05/28/21. SN visits were conducted on 05/14/25, 05/30/25 and on 07/03/25. The SN visit notes showed no patient request for discharge and no discharge from agency services. At 10:10 a.m., Staff A stated: 1. The patient was discharged from agency services on 07/03/25. 2. The SN visit on 07/03/25 was scheduled as a routine SN visit and discharge OASIS documentation was not completed. 3. The clinical record showed no reason for discharge, no patient request for discharge and no physician notification of discharge.”

“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 visits were conducted as ordered for two (Patients #6 and #7) of seven patients. Findings: Patient #1 A review of the POC dated 02/06/25 to 04/06/25 showed orders for SN visits once a week for six weeks, then one time every two weeks for two weeks. SN communication notes dated 03/01/25 and 03/04/25 showed SN missed visits due to “scheduling errors”. The SN communication notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/16/25 at 2:10 p.m., Staff A stated the SN should have provided SN visits as ordered on the POC. Patient #7 A review of the POC dated 02/02/25 to 04/02/25 showed orders for SN visits once a week for five weeks, then one time every two weeks for four weeks. SN communication notes dated 03/01/25 and 03/04/25 showed SN missed visits due to “scheduling errors”. The SN communication notes showed no patient refusal of care, no physician notification and no changes in orders. On 07/16/25 at 2:20 p.m., Staff A stated the SN should have provided SN visits as ordered on the POC.”

“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: 1. A completed transfer summary was provided to the receiving service provider within 2 days of notification of in-patient admission for two (Patients #4 and #6) of seven patients. 2. A completed discharge summary was provided within 5 calendar days of discharge to the physician for one (Patient #7) of seven patients. Findings: Patient #4 A review of the clinical record showed an inpatient hospital transfer date of 12/06/24. The clinical record showed the agency was notified of the inpatient transfer on 12/06/24 and showed the transfer summary was provided to the inpatient facility on 12/11/24 (five days later). Patient #6 A review of the clinical record showed an inpatient hospital transfer date of 03/21/25. The clinical record showed the agency was notified of the inpatient transfer on 03/21/25 and showed the transfer summary was provided to the inpatient facility on 03/26/25 (five days later). Patient #7 A review of the clinical record showed a discharge date of 04/02/25. The clinical record showed the discharge summary was provided to the physician on 04/29/25 (27 days later). On 07/16/25 at 2:20 p.m., Staff A stated: 1. The receiving service provider should have received a copy of a transfer summary for patients #4 and #6 within 2 days of a transfer. 2. The physician should have received a copy of a discharge summary within 5 days of patient #7 discharge from agency services.”