Carter Healthcare of Northeast Oklahoma, LLC

“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 all hazards risk assessment was developed that identified the agency and its branch location for all patients and employees. Findings: A review of emergency preparedness records showed risk assessments dated 2024 and 2025. The risk assessments did not identify the agency or its branch site location. On 08/13/26 at 10:45 a.m., Staff A stated the risk assessments did not identify 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 required current employee contact information and current address information for the agency, for all patients and employees. Findings: A review of emergency preparedness records showed a staff roster that included staff contact information for staff that no longer worked for the agency and did not include staff contact information for the branch operating site. On 08/13/26 at 10:45 a.m., Staff A stated the emergency preparedness communication plan had not been updated to include contact information for current employees of the agency.”

“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 notice or HHCOC notice prior to discharge from agency services were provided to one (Patient #7) of seven patients. Findings: Patient #7 A review of the clinical record showed no advance notice of discharge or home health change of care notice was provided to the patient prior to discharge from the agency on 06/19/26 for no insurance authorization. On 08/13/26 at 10:35 a.m., Staff A stated the patient was not given advance notice of 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 evaluation of services or a start of care assessment was conducted within 48 hours of referral for one (Patient #7) of seven patients. Findings: Patient #7 A review of the clinical record showed the agency received referral information on 06/04/26 and the SOC assessment occurred on 06/12/26 (8 days). The clinical record showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 08/13/26 at 10:35 a.m., Staff A stated there were no reasons documented for the delay in care.”

“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 individualized patient POC’s included: Pain management reporting parameters for four (Patients #1, 2, 3 and #4) of seven patients.Physical therapy discipline orders for two (Patients #4 and #7) of seven patients. Findings: Patient #1 A review of a POC dated 07/13/26 to 09/10/26 showed orders for SN to assess and instruct on pain management interventions. SN visit notes dated 07/16/26, 07/23/26, 07/30/26 and on 08/01/26 showed patient reported pain levels of 2 and 3 of 10. The POC showed no pain level reporting parameters, no physician notifications and no change in orders. Patient #2 A review of a POC dated 05/26/26 to 07/24/26 showed orders for SN to assess and instruct on pain management interventions. SN visit notes dated 06/11/26, 06/16/26, 06/22/26, 06/29/26 and on 07/10/26 showed patient reported pain levels of 2 and 3 of 10. The POC showed no pain level reporting parameters, no physician notifications and no change in orders Patient #3 A review of a POC dated 06/27/26 to 08/25/26 showed orders for SN to assess and instruct on pain management interventions. PT visit note dated 07/09/26 showed patient reported pain levels of 4 of 10. The POC showed no pain level reporting parameters, no physician notifications and no change in orders. Patient #4 A review of a POC dated 06/21/26 to 08/19/26 showed orders for SN to assess and instruct on pain management interventions and showed a physical therapy frequency of one time a month for one month with no evaluation and treatment interventions or stated goals. SN visit notes dated 07/10/26, 07/16/26, 07/23/26, 07/30/26 and on 08/03/26 showed patient reported pain levels of 2 and 3 of 10. The POC showed no pain level reporting parameters, no physician notifications and no change in orders. Patient #7 A review of a POC dated 06/12/26 to 08/10/26 showed orders for physical therapy frequency of one time a month for one month with no evaluation and treatment interventions or stated goals. The POC showed no physician notifications and no change in orders.SN On 08/13/26 from 9:50 a.m. to 10:35 a.m., Staff A stated: The POCs for patients #1, 2, 3 and #4 had no pain level reporting parameters.The POCs for patients #4 and #7 had no orders specific to physical therapy.”

“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 were a part of the patient plans of care for: SN to administer injectable medication every week for one (Patient #1) of seven patients.SN to perform wound site care for one (Patient #6) of seven patients. Findings: Patient #1 A review of the POC dated 07/13/26 to 09/10/26 showed no orders for SN to administer subcutaneous injectable medication (Mounjaro 7.5 milligrams) every week. SN visit notes dated 07/16/26, 07/23/26, 07/30/26 and on 08/01/26 showed the SN administered Mounjaro 7.5 milligrams subcutaneous injection during the visits. The clinical record showed no physician notification and no changes in orders. On 08/13/26 at 9:50 a.m., Staff A stated the POC showed no physician order transcription into the clinical record for the medication administration, no physician notification, and no changes in orders. Patient #6 A review of the POC dated 05/30/26 to 07/28/26 showed no orders for SN to perform wound site care to the left knee. SN visit notes dated 06/01/26, 06/08/26, 06/15/26 and on 06/22/26 showed the SN performed wound care to the left knee of cleansed site with wound wash (Vasche), applied calcium alginate, covered with silver dressings during the visits. The clinical record showed no physician notification and no changes in orders until 06/30/26. On 08/13/26 at 9:50 a.m., Staff A stated the POC showed no physician order transcription into the clinical record for the wound care until 6/30/26.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 one (Patient #5) of seven patients. Findings: Patient #5 A review of the POC dated 06/01/26 to 07/30/26 showed orders for a SN visit frequency of one time a week for nine weeks to assess, instruct and perform wound site care to the left foot of cover with dry gauze, wrap with Kerlex and ace wrap. SN visit notes dated 06/08/26, 06/15/26, 06/22/26, 06/29/26 and on 07/06/24 documented the patient’s caregiver (spouse) had performed the wound care prior to the SN visits and the SN visit notes showed no wound site assessments. A communication note dated 07/17/26 documented the SN visit was missed due to no answer to telephone call or text. The clinical record showed no attempt to make up the visit. The clinical record showed no physician communications or coordination of care notes related to SN not assessing the wound site and performing the wound care during the weekly SN visits and showed no changes in orders. On 08/13/26 at 10:10 a.m., Staff A stated the SN should have communicated to the physician that the patient’s caregiver was adept at changing the wound site dressing and assessment of the wound site was not being conducted.”

“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: PT visit frequency was conducted for two (Patients #2 and #4) of seven patients.SN visit frequencies were conducted as ordered for one (Patient # 4) of seven patients.SN report patient weight less than 250 pounds to the physician for one (Patient #6) of seven patients. Findings: Patient #2 A review of the POC dated 05/26/26 to 07/24/26 showed orders for PT visit frequency of one time a week for nine weeks. The clinical record showed a missed PT visit on 06/05/26 due to no insurance authorization and showed no patient/caregiver refusal of the visit, no physician notification, and no change in orders. Patient #4 A review of the POC dated 06/21/26 to 08/19/26 showed orders for PT visit frequency of one time a week for one week, two times a week for one week, then one time a week for three weeks and a SN visit frequency of one time a week for nine weeks. The clinical record showed a missed PT visit on 07/03/26 due to “patient in care of family” and no SN visits during the weeks of 06/21/27 to 06/27/26 (one visit ordered, no visit conducted) and 06/28/26 to 07/04/26 (one visit ordered, no visit conducted). The clinical record showed no patient/caregiver refusal of the visits, no physician notifications, and no change in orders. Patient #6 A review of the POC dated 05/30/26 to 07/28/26 showed orders for SN to weigh the patient every visit and report patient weight less than 250 pounds to the physician. A SN visit note dated 06/01/26 showed a patient’s weight of 223 pounds and showed no physician notification, and no change in orders. On 08/13/26 from 9:55 a.m. to 10:20 a.m., Staff A stated: The PT should have attempted the visit or called to get an order to put PT on hold for patient #2.The PT and the SN should have made the visits as ordered for patient #4.The SN should have reported the weight to the physician for patient #6.”

“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 one (Patient #6) of seven patients. Findings: Patient #6 A review of the clinical record showed: A transfer from the agency to inpatient service provider on 06/22/26. The clinical record showed no transfer summary was provided to the service provider. A transfer from the agency to inpatient service provider on 07/15/26. The clinical record showed no transfer summary was provided to the service provider. A discharge from agency services on 07/28/26. The clinical record showed no discharge summary was provided to the ordering physician. On 08/13/26 at 10:20 a.m., Staff A stated: No transfer summary was sent to the receiving in-patient service provider.The discharge summary was not sent to the physician after the discharge.”