Carter Healthcare of Southwest Oklahoma, LLC

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. the physician was notified of PT and SN missed visits for two (Patients #1 and 4) of nine patients; 2. SN frequencies were followed as ordered for two (Patient #4 and 6) of nine patients; 3. SN notified the physician of systolic blood pressure outside the ordered parameters for one (Patient #6) of nine patients; and 4. SN notified the physician of weight outside the ordered parameter for one (Patient #6) of nine patients. 1. Patient #1 A review of the POC dated 05/04/24 to 07/02/24 showed a PT frequency of one visit per month for one month. A review of the medical record showed a PT missed visit dated 05/08/24 which documented the reason as family refused. Documentation showed no notification was made to the physician of the missed visit. Patient #4 A review of the POC dated 04/24/24 to 06/22/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 05/02/24 which documented the reason as patient/family declined, and no other visits for the week of 04/28/24 to 05/04/24. Documentation showed no notification was made to the physician of the missed visit. 2. Patient #4 A review of the POC dated 04/24/24 to 06/22/24 showed a SN frequency of one visit per week for nine weeks. A review of the medical record showed a SN missed visit dated 05/02/24 which documented the reason as patient/family declined, and no other visits for the week of 04/28/24 to 05/04/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #6 A review of the POC dated 04/07/23 to 06/05/23 showed a SN frequency of one visit per week for eight weeks, effective 04/19/23. A further review of a physician’s order dated 05/12/23 showed a SN frequency of one visit every other week for three weeks. A review of the medical record showed no SN visits were made for the week of 05/28/23 to 06/03/23. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 3. Patient #6 A review of the POC dated 04/07/23 to 06/05/23 showed an order for the physician to be notified of systolic blood pressure less than 90. A review of SN visit dated 05/05/23 showed a systolic blood pressure result of 88. Documents showed no physician notification for systolic blood pressure result less than 90. 4. Patient #6 A review of the POC dated 04/07/23 to 06/05/23 showed an order for the physician to be notified of weight greater than 100 pounds. A review of SN visit dated 05/05/23 showed a weight of 105 pounds. Documents showed no physician notification for weight greater than 100 pounds. On 05/16/24 at 11:36 a.m., Staff A stated: 1. there was no documentation of physician notification of PT and SN missed visits for Patients #1 and 4; 2. the SN frequencies for Patients #4 and 6 were not met as ordered by the physician; 3. there was no documentation of physician notification of systolic blood pressure being out of parameters for Patient #6; and 4. there was no documentation of physician notification of weight being out of 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 six patients and current employees. A review of the agency’s documentation showed no records of performance improvement projects implemented, in development, on-going or completed for calendar year 2023. On 05/16/24 at 11:40 a.m., Staff A stated the agency had no documentation which showed PIP activities for calendar year 2023.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of an operating budget and allocation of resources for calendar year 2023 effecting six patients and all staff. A review of administrative records showed no governing body over-site of the operating budget and allocation of resources for the agency in calendar year 2023. On 05/16/24 at 11:40 a.m., Staff A stated there was no documentation of governing body discussion of the operating budget or resource allocation needs for the agency for calendar year 2023.”

“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 a PT evaluation was conducted as ordered for one (Patient #3) of nine patients. A review of the POC dated 05/01/24 to 06/29/24 showed an order for PT to evaluate the week of 05/06/24. A review of the medical record showed no PT evaluation was conducted for the week of 05/05/24 to 05/11/24. Documentation showed no patient/caregiver refusal of services, no physician notification and no changes in the order. On 05/16/24 at 11:27 a.m., Staff A stated the PT evaluation for Patient #3 was not conducted as ordered by the physician.”