Every finding on record at Mays Homecall Home Health of Stillwater, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/15/24 to 05/16/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey in conjunction with investigation of complaint #101894 at the agency on 05/15/24 to 05/16/24. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for clinical issues and Staff C, D and E were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff C, D and E. Standard level deficiencies were cited as a result of the survey. Deficiencies were cited related to the complaint. Glossary: POC plan of care SN skilled nurse SOC start of care

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of a patient complaint for one (Patient #9) of nine patients. Findings: Patient #9 A review of the clinical record showed a pre-operative referral date of 05/09/23 and a second post operative referral date of 07/07/23 with a SOC date of 07/11/23. Documentation showed the patient had requested SOC on 07/08/23 immediately after in-patient surgical services (surgical date of 07/05/23) at the time of initial referral to home care services and again after a second referral to home care services on 07/07/23. Documentation showed no patient refusal of care, no physician notification of delay of care and no changes in orders. A review of administrative records showed no documentation of the patient’s complaint of a delay in home care services (in patient discharge date of 07/07/23, patient requested SOC date of 07/08/23 and home services SOC date of 07/11/23). On 05/15/24 at 3:30 p.m., Staff C stated administrative records related to complaints, incidents, and grievances for calendar year 2023 were provided in their entirety and showed no complaints, incidents, and grievances for the months of July and August calendar year 2023. On 05/16/24 at 11:20 a.m., Staff D stated documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 07/11/23 SOC date.

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 start of care within 48 hours of referral for eight (Patients #2, 3, 4, 5, 6, 7, 8 and #9) of nine patients. Findings: Patient #2 A review of the clinical record showed a referral date of 11/02/22 and a SOC date of 11/08/22 (6 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 10:51 a.m., Staff D stated that: 1. A coordination note dated 11/16/22 (14 days after the referral date and 8 days after the SOC date) showed that the patient requested an 11/08/22 SOC date and; 2. Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to 11/16/22 coordination note. Patient #3 A review of the clinical record showed a referral date of 03/25/24 and a SOC date of 04/16/24 (21 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 10:53 a.m., Staff D stated that documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 04/16/24 SOC date. Patient #4 A review of the clinical record showed a referral date of 01/05/24 and a SOC date of 01/16/24 (11 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 11:00 a.m., Staff D stated that documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 01/16/24 SOC date. Patient #5 A review of the clinical record showed a referral date of 04/26/24 and a SOC date of 04/29/24 (3 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 11:05 a.m., Staff D stated that documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 04/29/24 SOC date. Patient #6 A review of the clinical record showed a referral date of 01/03/23 and a SOC date of 01/09/23 (6 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 11:06 a.m., Staff D stated that documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 01/09/23 SOC date. Patient #7 A review of the clinical record showed a referral date of 12/29/23 and a SOC date of 01/05/24 (6 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 11:11 a.m., Staff D stated that documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 01/05/24 SOC date. Patient #8 A review of the clinical record showed a referral date of 04/20/23 and a SOC date of 04/28/23 (7 days). Documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 11:16 a.m., Staff D stated that documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 04/28/23 SOC date. Patient #9 A review of the clinical record showed a pre-operative referral date of 05/09/23, a post operative referral date of 07/07/23 and a SOC date of 07/11/23 (4 days). Documentation showed no patient refusal of care, no physician notification of delay of care and no changes in orders. On 05/16/24 at 11:20 a.m., Staff D stated that documentation showed no patient/caregiver refusal of care, no physician notification of delay of care and no changes in orders prior to the 07/11/23 SOC date.

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 included: 1. Pain monitoring and reporting parameters for physician notification for two (patients #1 and #3) of nine patients and; 2. Identified wound site care for one (Patient #3) of nine patients. Findings: Patient #1 A review of the POC dated 04/15/24 to 06/13/24 showed orders for SN to assess, instruct pain management and report to physician patient reported tolerable pain levels on 0-10 scale. Documentation showed patient reported pain levels during SN visits conducted on 04/30/24 of 4. Documentation showed no physician reporting parameter, no physician notifications, and no changes in orders. On 05/16/24 at 10:50 a.m., Staff D stated the POC for patient #1 did not include physician reporting parameters for patient pain management instruction. Patient #3 A review of the POC dated 04/16/24 to 06/14/24 showed a frequency order for SN services for wound site care and management to stage 3 pressure ulcer with pain assessment and pain management instruction one time a week for one week, two times a week for one week, one time a week for three weeks then one time every two weeks for four weeks. Documentation showed no wound site care for stage 3 pressure ulcer and showed no reporting parameters for physician notification of pain levels. An update to the POC dated 04/28/24 documented wound site care to the stage 3 pressure ulcer. Documentation showed no physician notifications and no change in orders from 04/15/24 to 04/28/24 (13 days). Documentation showed patients reported pain levels during SN visits conducted on 05/03/24 of 4 and on 05/10/24 of 1. Documentation showed no physician notifications, and no changes in orders. On 05/16/24 at 10:53 a.m., Staff D stated the POC dated effective 04/16/24 did not include wound site care for stage 3 pressure ulcer and showed no physician reporting parameters for patient pain management instruction.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of changes in conditions for one (Patient #7) of nine patients. Findings: Patient #7 A plan of care dated 01/05/24 to 03/04/24 documented diagnoses of malignant poorly differentiated neuroendocrine tumor. Documentation showed orders for SN visit frequency of one time a week for one week, two times a week for one week then one time a week for seven weeks to perform assessment and monitoring of health conditions every visit. Documentation for week of 01/07/24 to 01/13/24 showed a missed visit on 01/12/24 (one visit conducted, one visit missed), week of 01/14/24 to 01/20/24 one visit missed on 01/18/24 (one visit ordered, no visit conducted), week of 01/21/24 to 01/31/24 one visit missed on 01/24/24 (one visit ordered, no visit conducted). Documentation showed missed visits were auto faxed to the physician but showed no follow up communication to the physician that the missed visit frequency continued over a three-week period until the patient was discharged to hospice provider services on 01/31/24. Documentation showed no physician provider notifications or coordination of care communications related to changes in the patient’s change in condition, continued missed SN visits and no changes in orders. On 05/16/24 at 11:11 a.m., Staff D stated the agency did not notify the physician of changes in the patient’s condition and showed no follow up communication to the physician that the missed visit frequency continued over a three-week period until the patient was discharged to hospice provider services on 01/31/24.

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 SN conducted wound site assessment with measurements weekly for one (Patient #4) of nine patients. Findings: Patient #4 A review of the POC dated 03/16/24 to 05/14/24 showed orders for SN visit frequency of one time a week for nine weeks for wound site assessment and measurements weekly. Documentation showed no wound site measurements during SN visits on 04/03/24, 04/09/24, 04/16/24 and on 04/26/24. Documentation showed no patient/caregiver refusal of wound site measurements, no physician notifications, and no change in orders. On 05/16/24 at 11:00 a.m., Staff D stated the SN visit documentation showed no measurements of the wound site during the weekly SN visits on 04/03/24, 04/09/24, 04/16/24 and on 04/26/24.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit note documentation was completed within 24 hours of the visit for one (Patient #2) of nine patients. Findings: Patient #2 A review of the POC dated 03/02/24 to 04/30/24 showed orders for SN visit frequency of one time a week for two weeks then one times every three weeks for six weeks. Documentation showed SN visit dated 02/25/24 was completed on 03/05/24 (9 days from the date of the visit) and 02/29/24 was completed on 03/07/24 (6 days from the date of the visit). Documentation showed no documentation as to why the visit note was not completed within 24 hours of the visit. On 05/16/24 at 10:51 a.m., Staff D stated: 1. Visit note documentation is due 24 hours from the time a visit is completed and; 2. SN visit documentation was not completed timely for patient #2.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/18/21 to 05/19/21. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 05/18/21 through 05/19/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical issues and Staff B and C were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff C, D, E, F and G. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: HHA Home Health Agency PoC Plan of Care RN Registered Nurse SN Skilled Nurse

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 an advance beneficiary notice was provided to one (Patient #1) of seven patients. Findings: Patient #1 A review of the clinical record showed no advance beneficiary notice was given to the patient prior to discharge from the agency for a change in payer source on 04/07/21. On 05/19/21 at 10:44 a.m., Staff C stated no advance beneficiary notice was documented in the clinical record for patients #1 prior to being discharged from the agency.

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 recurring urinary catheter change due dates for one (Patient #6) of seven patients. Findings: Patient #6 A review of the plan of care dated 03/20/21 to 05/18/21 documented a principal diagnosis of multiple site stage 2 pressure ulcers. The POC showed orders for SN to change indwelling Foley catheter every month. POC documentation showed no dates the indwelling Foley catheter change was due. On 05/19/21 at 11:00 a.m., Staff C stated recurring urinary catheter change due dates should have been documented for Patient #1 in the POC.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA 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). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician notification of patient discharge from the HHA prior to an admission to hospice services for one (Patient #2) of seven patients. Findings: Patient #2 A review of a physician's order, dated 02/25/21 documented the patient's daughter informed the HHA the patient's oncologist was referring the patient to hospice services (the oncologist was not the referring physician or overseeing the planning of care). Clinical documentation showed no communication to the home health ordering physician the patient had been discharged from the home health agency prior to the referral and subsequent admission to the hospice service provider by the oncologist. On 05/19/21 at 10:52 a.m., Staff C stated the ordering physician for home health services for Patient #2 should have been notified of the patient's discharge from HHA services as soon as the HHA became aware of the pending referral and admission to hospice services.

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 SN performed weekly weights as ordered in the POC for one (Patient #4) of seven patients. Findings: Patient #4 A review of a plan of care dated 04/13/21 to 06/11/21 documented a diagnosis of pulmonary emboli showed an order for SN to weigh the patient weekly. Skilled nurse visit notes dated 04/30/21 and 05/13/21 showed no weight observation was conducted. Documentation showed no physician notification of the patient's refusal to weigh and no change in orders. On 05/19/21 at 10:54 a.m., Staff C stated the SN should have observed the patient's weight during the home visits.