Health Watch Health Care of Altus, LLC

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that an order was obtained for newly identified wounds for one (Pt #1) of seven patients. Findings: A policy titled Physician Communication read in part, the agency will establish and maintain communication with the physician or allowed practitioner to ensure safe and appropriate care for the patient/client... when there are significant changes in the patient’s/client’s medical condition, vital signs out of parameter. Pt #1 A review of the clinical record showed a SN assessment dated 11/07/25 identified new wounds to the right buttock (#4) and left buttock (#5). Wound care was provided as follows: cleansed with wound wash, patted dry with 4x4 gauze. Applied Triad cream to red areas. The SN assessment showed no physician notification of new wounds and no orders were obtained for wound care. On 12/10/25 at 1:58 pm, Staff B stated the physician for Pt #1 was not notified of the new wounds.”

“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 that a physician was notified of: 1) a change in skin integrity for one (Pt #1) of seven patients; 2) a pain level above acceptable level in a timely manner for one (Pt #1) of seven patients. Findings: A policy titled Coordination of Services with Other Clinicians read in part, Coordination includes but is not limited to: ... Initiation of communication with other organizations/individuals when there are changes in the patient’s/client’s overall care. A policy titled Physician Communication read in part, the agency will establish and maintain communication with the physician or allowed practitioner to ensure safe and appropriate care for the patient/client... when there are significant changes in the patient’s/client’s medical condition, vital signs out of parameter. Pt #1 A review of the clinical record for the certification period of 09/28/25 - 11/26/25 showed a SN assessment dated 11/07/25 identified two new wounds as #4 right buttock and #5 left buttock. The SN visit note showed no physician notification of new wounds sites and showed no orders were obtained for wound care. On 12/10/25 at 1:58 pm, Staff B stated the physician for Pt #1 was not notified of the additional wounds. Pt #2 A review of a POC for the certification period dated 07/03/25 - 08/31/25 showed an order to notify the physician if pain greater than 8. A nurse assessment dated 07/17/25 showed the patient reported a pain level of 10 out of 10 and showed no physician notification at the time of the assessment and no further follow up was noted. On 12/10/25 at 2:05 pm, Staff B stated the nursing assessment showed no physician notification the patient reported a pain level of 10 of 10 at the time of the visit.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the ordered visit frequency was followed for one (Pt #2) of four patients. Findings: Pt #2 A review of a POC dated 07/03/25 - 08/31/25 showed a PT ordered frequency beginning the week of 07/06/25 twice a week for three weeks. The following PT visits were noted during the week of 07/06/25 - 07/12/25 a PT visit dated 07/07/25, no other visit, no patient refusal, and no missed visit was completed (two visits ordered, one visit conducted). On 12/10/25 at 2:05 pm, Staff B stated there was only one PT visit during the week of 07/06/25.”

“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 services were provided as ordered in the POC for one (Pt #4) of four patients. Findings: Pt #4 A review of a POC dated 10/31/25 - 12/29/25 showed orders for a physical therapist to evaluate. The clinical record showed no PT evaluation was conducted, showed no physician’s order to cancel the PT evaluation, and no patient refusal of a PT evaluation. On 12/10/25 at 2:18 pm, Staff B stated no PT evaluation was conducted.”