Carter Healthcare of Northeast Oklahoma, LLC

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.

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.

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.

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.

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.

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.

The agency failed to ensure care was coordinated between the agency and physician for one (Patient #5) of seven patients.

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.

The agency failed to ensure a completed transfer/discharge summary was provided for one (Patient #6) of seven patients.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees.

The agency failed to: 1. Educate the patient on potential health outcomes related to refusal of PT and ST visits; and 2. Notify the physician of the patient's imminent discharge from agency services for continued refusal of PT and OT visits for one (Patient #15) of 17 patients.

The agency failed to ensure an individualized patient POC included: 1. Site of wound care interventions for one (Patient #16) of 17 and; 2. Pain reporting parameters for physician notification for one (Patient #16) of 17 patients.

The agency failed to ensure care was coordinated between the agency and physician for two (Patient #1 and #4) of 17 patients.

The agency failed to ensure services were provided as ordered on the POC’s: 1. SN to assess/monitor/report and instruct patient reported pain levels for four (Patients #1, 2, 3 and 11) of 17 patients; 2. SN to assess/monitor/report and instruct patient blood pressure level for one (Patients # 2) of…

The agency failed to ensure a completed transfer/discharge summary was provided for four (Patients #7, 13, 14 and 17) of 17 patients.