Choice Health at Home - Norman

“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 updated required employee contact information for the agency, for all patients and employees. Findings: A review of emergency preparedness records showed no updated communication plan which included current employee contact information. On 05/08/25 at 10:00 a.m., Staff A stated the communication plan was not updated to include current employee contact information.”

“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 interviews, the agency failed to ensure performance improvement project were documentation for meetings dated 04/26/23 (1st quarter 2023) to 10/30/24 (3rd quarter 2024) for all patients and employees. Findings: A review of QAPI records showed no performance improvement project from meetings dated 04/26/23 (1st quarter 2023) to 10/30/24 (3rd quarter 2024). On 05/08/25 at 9:00 a.m., Staff A stated the agency had no PIP documentation which showed interventions, analysis of data, follow up, or PIP status designation from the meetings dated 04/26/23 to 10/30/24.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit note documentation was correct for two (Patients #1 and #7) of nine patients. Findings: Patient #1 A review of the POC dated 04/11/25 to 06/09/25 showed orders for SN to evaluate for home health services and assess health conditions. A vital sign report showed a SN vital sign notation dated 04/07/25 (7 days before the SOC). Documentation showed a SOC date of 04/11/25. On 05/08/25 at 9:52 a.m., Staff A stated the vital sign notation dated 04/07/25 was a data entry error by the SN. The vital sign notation should have been dated 04/11/25. Patient #7 A review of the POC dated 02/07/25 to 04/07/25 showed orders for SN to evaluate for home health services and assess health conditions. A vital sign report showed a SN vital sign notation dated 02/06/25 (1 day before the SOC). Documentation showed a SOC date of 02/07/25. On 05/08/25 at 9:52 a.m., Staff A stated the vital sign notation dated 02/06/25 was a data entry error by the SN. The vital sign notation should have been dated 02/07/25.”

“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 a SOC assessment was conducted within 48 hours of referral for one (Patient #7) of nine patients. Findings: Patient #7 A review of the clinical record showed the agency received referral information on 02/03/25 and the SOC assessment occurred on 02/07/24 (4 days later). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 05/08/25 at 9:52 a.m., Staff A stated the SOC assessments for patient #7 should have been conducted within 2 days of referral.”

“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 patient POC included SN interventions for assessment, instruction and monitoring effectiveness of anticoagulant therapy for three (Patients #1, 5 and #7) of nine patients. Findings: Patient #7 A review of the POC dated 02/07/25 to 04/17/25 showed orders for SN to assess, instruct and monitor effectiveness of anticoagulant therapy. The POC showed no SN interventions to instruct and monitor effectiveness of anticoagulant therapy. Documentation showed no physician notifications and no change in orders. On 05/08/25 at 9:52 a.m., Staff A stated the POC identified no SN interventions to instruct and monitor effectiveness of anticoagulant 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 patients’ plan of care for three (Patients #1, 5 and 8) of nine patients. Findings: Patient #1 A POC dated 04/11/25 to 06/09/25 showed orders for OT to evaluate once a week for one week. A missed visit note was dated 04/18/25 and showed no attempts to make up the visit (one visit ordered and no visit conducted). Documentation showed no OT follow up and no subsequent OT evaluation. A coordination of care note dated 05/01/25 showed the OT evaluation should be moved to 04/21/25. Documentation showed no physician notification of the missed evaluation and no changes in orders. On 05/08/25 at 9:13 a.m., Staff A stated the order to change the OT evaluation was not written on the POC. The documentation showed no physician notification and no further changes in orders. Patient #5 A review of the POC dated 04/01/25 to 05/30/25 showed orders for PT frequency of two times a week for one week, two times a week for two weeks, two times a week for two weeks, then one time a week for one week. During the week of 04/01/25 to 04/05/25, a PT visit was conducted on 04/04/25 (two visits ordered and one visit conducted). A coordination of care note dated 04/08/25showed a PT frequency of one time a week for one week, two times a week for three weeks, then one time a week for one week. Documentation showed no changes to the POC and no update in scheduled visits, and no new orders. On 05/08/25 at 9:31 a.m., Staff A stated the order to change the PT frequency and duration was not written on the POC, there was no physician notification of missed visits, and no additional changes in orders. Patient #8 A review of the POC dated 02/04/25 to 04/04/25 showed orders for PT frequency of two times a week for one week, one time a week for one week, two times a week for one week, then one time a week for six weeks. During the week of 02/04/25 to 02/08/25, a PT visit was conducted on 02/05/25 (two visits ordered and one visit conducted). A coordination of care note dated 02/07/25 showed effective 02/05/25, a PT frequency and duration of one time a week for one week, two times a week for two weeks, then one time a week for six weeks. Documentation showed no changes to the POC, no updates in scheduled visits, and no new orders. On 05/08/25 at 10:00 a.m., Staff A stated the order to change the PT frequency and duration was not written on the POC, there was no physician notification of missed visits, and no changes in orders.”

“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 two (Patients #6 and #8) of nine patients. Findings: Patient #6 A review of the POC dated 02/17/25 to 04/17/25 showed a diagnosis of Diabetes Mellitus, Type II with chronic kidney disease. Documentation showed changes in the patient’s assessment from 03/19/25 to 04/17/25 as follows: on 03/19/25 SN documented the patient had 4+ edema to the right lower extremity and 3+ edema to the left lower extremity; on 04/02/25 the patient’s bilateral lower extremities were red and swollen with a copious amount of fluid weeping from the tissue; on 04/04/25 the patient assessment showed 4+ bilateral edema with copious of fluid weeping from the tissue and abdominal distention and the patient refused to weigh; on 04/17/25 the patient assessment showed 4+ edema with continued copious of fluid weeping from the tissue and abdominal distention. Documentation showed a request to auto-fax notification of the patient assessment to the physician on 04/04/25. Documentation showed no follow up physician communications or coordination of care notes related to the patient continuing to have 3-4+ edema and red and swollen bilateral lower extremities, abdominal distention and showed no changes in orders. On 05/08/25 at 9:39 a.m., Staff A stated the SN should have communicated the patient’s continued 3-4+ edema and red and swollen bilateral lower extremities accompanied with abdominal distention. Patient #8 A review of the POC dated 02/04/25 to 04/04/25 showed a diagnosis of hypertension with heart failure. A coordination of care note dated 02/07/25 showed the patient requested discharge from home health services. A coordination of care note dated 02/20/25 showed effective 02/18/25 discharge per the patient’s request. Documentation showed a discharge from agency services on 02/17/25. Documentation showed no physician communications or coordination of care notes related to the patient request to discharge prior to the discharge date and showed no changes in orders. On 05/08/25 at 10:00 a.m., Staff A stated the SN should have communicated the patient’s request for discharge from agency services prior to the date 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: 1. OT visit frequency and duration were conducted as ordered for one (Patient #1) of nine patients. 2. SN visit frequency and duration as ordered for two (Patients #2 and #4) of nine patients. 3. SN monitored a patient’s blood sugar every visit as ordered for two (Patients #3 and #6) of nine patients. 4. PT visit frequency and duration as ordered for three (Patients #5, 6 and #7) of nine patients. Findings: Patient #1 A review of the POC dated 04/11/25 to 06/09/25 showed orders for OT to evaluate effective 04/13/25. A review of visit notes showed no OT evaluation from 04/13/25 to 05/03/25 and showed no patient or caregiver refusal, no physician notification and no changes in orders. On 05/08/25 at 9:13 a.m., Staff A stated the patient had no OT evaluation as ordered on the POC. Patient #2 A review of the POC dated 03/19/25 to 05/17/25 showed orders for SN to assess, instruct and monitor. Documentation showed a visit frequency of one week one, then two times a week for eight weeks. During the week of 04/20/25 to 04/26/25 documentation showed no SN visit (one visit ordered, no visit conducted), no patient or caregiver refusal, no physician notification and no changes in orders. On 05/08/25 at 9:19 a.m., Staff A stated the during the week of 04/20/25 to 04/26/25 the patient had no SN visit as ordered on the POC. Patient #3 A review of the POC dated 04/19/25 to 06/16/25 showed orders for SN to assess, monitor, instruct the patients’ blood sugar, and report random blood sugar levels less than 60 and greater than 300 to the physician every visit . A further review of orders showed a visit frequency of one week one, then one times a week every two weeks for four weeks. A review of SN visits showed no assessment of the patient’s blood sugar during visits dated 04/25/25 and 05/02/25. Documentation showed no patient or caregiver refusal of blood sugar monitoring, no physician notification and no changes in orders. On 05/08/25 at 9:23 a.m., Staff A stated the SN visit notes dated 04/25/25 and 05/02/25 showed no SN interventions for blood sugar monitoring. Patient #4 A review of the POC dated 04/01/25 to 05/30/25 showed orders for SN to assess, instruct and monitor one time a week for nine weeks. During the week of 04/20/25 to 04/26/25 documentation showed no SN visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 05/08/25 at 9:26 a.m., Staff A stated the during the week of 04/20/25 to 04/26/25 the patient had no SN visit as ordered on the POC. Patient #5 A review of the POC dated 04/01/25 to 05/30/25 showed orders for PT frequency of two weeks one for one week, two every two weeks for two weeks, two times a week for two weeks, then once a week for one week. A review of visit notes showed during the week of 04/01/25 to 04/05/25 a visit was conducted on 04/04/25 (two visits ordered, one visit conducted). Documentation showed no patient or caregiver refusal of visits, no physician notification and no changes in orders. On 05/08/25 at 9:31 a.m., Staff A stated the PT visits should have been conducted as ordered on the POC. Patient #6 A review of the POC dated 02/17/25 to 04/17/25 showed orders for SN to assess, instruct, monitor, instruct the patients’ blood sugar, and report random blood sugar levels less than 60 and greater than 300 to the physician every visit. Further documentation showed a visit frequency of one week one, two week one, then one times a week for five-weeks and PT orders for one evaluation. A review of visit notes showed no PT evaluation during the week of 02/17/25 to 02/22/25 (one visit ordered, no visit conducted) and no assessment of the patient’s blood sugar during SN visits dated 03/11/25, 03/13/25, 03/19/25, 03/25/25, 04/01/25, 04/08/25 and 04/11/25. Documentation showed no patient or caregiver refusal of visits and/or blood sugar monitoring, no physician notification and no changes in orders. On 05/08/25 at 9:39 a.m., Staff A stated the SN interventions for blood sugar monitoring and the PT evaluation should have been conducted as ordered by the physician. Patient #7 A review of the POC dated 02/07/25 to 04/07/25 showed orders for PT to evaluate effective 02/07/25. A review of visit notes showed no PT evaluation for the week of 02/07/25 to 02/08/25 (one visit ordered, no visit conducted) and showed no patient or caregiver refusal, no physician notification and no changes in orders. On 05/08/25 at 9:52 a.m., Staff A stated the PT evaluation should have been conducted 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 completed discharge summaries were provided to receiving service providers for two (Patients #6 and #7) of nine patients. Findings: Patient #6 A review of the clinical record showed discharge from the agency on 04/17/25 to hospice. Documentation showed no coordination of care report or discharge summary was provided to the receiving hospice. Patient #7 A review of the clinical record showed transfer from the agency on 03/11/25 to in-patient hospital services. Documentation showed no coordination of care report or transfer summary was provided to the receiving in-patient hospital. On 05/08/25 at 9:39 a.m. to 9:52 a.m., Staff A stated there was no transfer or discharge summary sent to the receiving providers for patients #6 and #7.”