Carter Healthcare of South Oklahoma, LLC

“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 oversight of the agency for 2023 and from January 01, 2024, to December 05, 2024. A review of administrative records showed no governing body minutes which documented the oversite specific to the surveyed agency’s function and programs for 2023 and from January 01, 2024, to December 05, 2024. On 12/04/24 at 2:20 pm., Staff A stated they were unable to locate documentation of oversite specific to the surveyed agency’s function and programs. On 12/05/24 at 10:55 am., Staff B stated they were unable to locate documentation of oversite specific to the surveyed agency’s function and programs.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of notification of the potential for discharge for cause was provided to the patient for one (Patient #7) of 13 patients. A review of the plan of care dated 03/15/24 to 05/13/24 showed a primary diagnosis of nondisplaced zone I fracture of sacrum with a skilled nurse frequency of one visit per day for one day, one visit per week for three weeks and one visit every other week for five weeks. A review of the clinical record showed the following; A start of care assessment dated 03/15/24 documented no power of attorney or medical power of attorney. A skilled nurse assessment dated 03/20/24 documented after arriving at the patient’s house and being invited inside, the patient was “sitting down a pistol that was drawn and pointed toward the direction of the front door”, with the nurse continuing her assessment with no documentation of issues or addressing the patient’s behavior. A communication note dated 03/21/24 documented by Staff #1 showed the nurse stated “the patient had a pistol drawn and pointed at her” (this was not documented in the original account of the assessment). A communication note dated 03/21/24 documented the patient family was notified of the potential need for discharge for cause (documentation showed no attempts to contact the patient). A communication note dated 03/21/24 documented the primary care physician’s nurse was in agreement with the patient needing to be discharged and the primary care physician would be notified. No orders were received for the discharge of the patient. On 12/04/24 at 1:25 pm., Staff A stated Patient #7 was not provided information in regards to the potential for discharge for cause.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of efforts to resolve the patient’s behavior for one (Patient #7) of 13 patients. A review of the plan of care dated 03/15/24 to 05/13/24 showed a primary diagnosis of nondisplaced zone I fracture of sacrum with a skilled nurse frequency of one visit per day for one day, one visit per week for three weeks and one visit every other week for five weeks. A review of the clinical record showed the following; A start of care assessment dated 03/15/24 documented no power of attorney or medical power of attorney. A skilled nurse assessment dated 03/20/24 documented after arriving at the patient’s house and being invited inside, the patient was “sitting down a pistol that was drawn and pointed toward the direction of the front door”, with the nurse continuing her assessment with no documentation of issues or addressing the patient’s behavior. A communication note dated 03/21/24 documented by Staff #1 showed the nurse stated “the patient had a pistol drawn and pointed at her” (this was not documented in the original account of the assessment). A communication note dated 03/21/24 documented the patient family was notified of the potential need for discharge for cause (documentation showed no attempts to contact the patient). A communication note dated 03/21/24 documented the primary care physician’s nurse was in agreement with the patient needing to be discharged and the primary care physician would be notified. No orders were received for the discharge of the patient. On 12/04/24 at 1:25 pm., Staff A stated Patient #7 there was no documentation of efforts to resolve the negative behaviors of Patient #7.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure it provided contact information to other agencies to provide care for one (Patient #7) of 13 patients. A review of the plan of care dated 03/15/24 to 05/13/24 showed a primary diagnosis of nondisplaced zone I fracture of sacrum with a skilled nurse frequency of one visit per day for one day, one visit per week for three weeks and one visit every other week for five weeks. A review of the clinical record showed the following; A start of care assessment dated 03/15/24 documented no power of attorney or medical power of attorney. A skilled nurse assessment dated 03/20/24 documented after arriving at the patient’s house and being invited inside, the patient was “sitting down a pistol that was drawn and pointed toward the direction of the front door”, with the nurse continuing her assessment with no documentation of issues or addressing the patient’s behavior. A communication note dated 03/21/24 documented by Staff #1 showed the nurse stated “the patient had a pistol drawn and pointed at her” (this was not documented in the original account of the assessment). A communication note dated 03/21/24 documented the patient family was notified of the potential need for discharge for cause (documentation showed no attempts to contact the patient). A communication note dated 03/21/24 documented the primary care physician’s nurse was in agreement with the patient needing to be discharged and the primary care physician would be notified. No orders were received for the discharge of the patient. On 12/04/24 at 1:25 pm., Staff A stated Patient #7 was not provided contact information for other agencies to provide 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 an individualized plan of care was developed for five (Patients #1, 2, 4, 10 and 12) of 13 patients. Patient #1 A review of the plan of care dated 08/15/24 to 10/12/24 showed a primary diagnosis of migraine with no patient specific individualized interventions and goals developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 08/22/24 to 10/20/24 showed a primary diagnosis of Alzheimer’s disease with no patient specific individualized interventions and goals developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 08/20/24 to 10/18/24 showed a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure with no patient specific individualized interventions and goals developed for the management of the primary diagnosis. Patient #10 A review of the plan of care dated 07/29/24 to 09/26/24 showed a primary diagnosis of diabetes mellitus type II with no patient specific individualized interventions and goals developed for the management of the primary diagnosis. Patient #12 A review of the plan of care dated 09/11/24 to 11/09/24 showed a primary diagnosis of primary generalized osteoarthritis with no patient specific individualized interventions and goals developed for the management of the primary diagnosis. On 12/05/24 at 10:50 am, Staff A stated the plan of care for Patients #1, 2, 4, 10 and 12 were not individualized with patient specific interventions and goals for the management of the primary diagnosis.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were obtained and documented in the clinical record for one (Patient #7) of 13 patients. A review of the plan of care dated 03/15/24 to 05/13/24 showed a primary diagnosis of nondisplaced zone I fracture of sacrum with a skilled nurse frequency of one visit per day for one day, one visit per week for three weeks and one visit every other week for five weeks. A review of the clinical record showed the following; A start of care assessment dated 03/15/24 documented no power of attorney or medical power of attorney. A skilled nurse assessment dated 03/20/24 documented after arriving at the patient’s house and being invited inside, the patient was “sitting down a pistol that was drawn and pointed toward the direction of the front door”, with the nurse continuing her assessment with no documentation of issues or addressing the patient’s behavior. A communication note dated 03/21/24 documented by Staff #1 showed the nurse stated “the patient had a pistol drawn and pointed at her” (this was not documented in the original account of the assessment). A communication note dated 03/21/24 documented the patient family was notified of the potential need for discharge for cause (documentation showed no attempts to contact the patient). A communication note dated 03/21/24 documented the primary care physician’s nurse was in agreement with the patient needing to be discharged and the primary care physician would be notified. No orders were received for the discharge of the patient. On 12/04/24 at 1:25 pm., Staff A stated verbal orders for discharge for cause were not in the clinical record for Patient #7.”