Every finding on record at Mays Housecall Home Health of Ada, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/05/24 to 11/06/24. 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 at the agency on 11/05/24 to 11/06/24. An entrance conference was conducted with Staff A. 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 B, C, J and K and by phone Staff D, E, F, G, H and I. Deficiencies were cited as a result of the re-certification survey.

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 for ten (Patient #1, 2, 3, 4, 6, 7, 8, 9 and 10) of 10 patients. Patient #1 A review of the plan of care dated 08/24/24 to 10/22/24 showed a primary diagnosis of essential (primary) hypertention with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 07/13/24 to 09/10/24 showed a primary diagnosis of peripheral vascular disease with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 09/05/24 to 11/03/24 showed a primary diagnosis of chronic kidney disease with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 09/10/24 to 11/08/24 showed a primary diagnosis of fracture of right shoulder girdle with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 08/09/24 to 10/07/24 showed a primary diagnosis of pressure ulcer sacral region stage IV with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 07/27/24 to 09/24/24 showed a primary diagnosis of congestive heart failure with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 08/16/24 to 10/14/24 showed a primary diagnosis of acute and chronic resp failure with hypoxia with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #8 A review of the plan of care dated 07/19/24 to 09/16/24 showed a primary diagnosis of unspecified atrial fibrillation with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #9 A review of the plan of care dated 09/11/24 to 11/09/24 showed a primary diagnosis of malignant neoplasm of esophagus with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #10 A review of the plan of care dated 09/26/24 to 11/24/24 showed a primary diagnosis of rectal abscess with no patient specific individualized interventions developed for the management of the primary diagnosis. On 11/06/24 at 12:50 pm, Staff B stated the plan of care for Patients #1, 2, 3, 4, 6, 7, 8, 9 and 10 were not individualized for the patient specific management of the primary diagnosis.

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 a significant weight change for one (Patient #6) of ten patients. Patient #6 A review of the plan of care dated 07/27/24 to 09/24/24 showed a skilled nurse frequency of one visit per week for nine weeks and documented a diagnosis of congestive heart failure. A review of the clinical record showed the following: A skilled nurse assessment dated 08/01/24 documented a weight of 216 pounds. A skilled nurse assessment dated 08/08/24 documented a weight of 200 pounds (a 16-pound weight loss from the previous assessment). A skilled nurse assessment dated 08.27/24 documented a weight of 200 pounds. A skilled nurse resumption of care assessment dated 08/31/24 documented a weight of 236 pounds (a 36-pound weight increase in four days) with no physician notification of the 36-pound weight increase within the four-day period. A skilled nurse assessment dated 09/05/24 documented a weight of 230 pounds. A skilled nurse assessment dated 09/12/24 documented a weight of 241 pounds (an 11-pound wight increase in seven days) with no physician notification of the 11- pound weight increase within a seven-day period. A skilled nurse assessment dated 09/19/24 documented a weight of 229 pounds (a twelve-pound weight loss in seven days) with no physician notification of the twelve-pound weight decrease within a seven-day period. A skilled nurse assessment dated 09/24024 documented a weight of 236 pounds (a seven-pound weight increase in five days) with no physician notification of the seven-pound weight increase within a five-day period. On 11/06/24 at 1:35 pm., Staff B stated the physican should have been notifed of the significant weight changes for Patient #6.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program Program survey at the agency from 12/15/21 to 12/16/21. 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 12/15/21 to 12/16/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff B, C and D were identified as the contact persons for administrative issues and Staff B and E were identified as the contact persons for clinical issues. Findings were discussed during an informal exit conference with Staff B, C, D and E and by phone with Staff F and G. Deficiencies were cited as a result of the re-certification survey.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. weights were obtained as ordered and wound care orders were followed as ordered for two (Patients #2 and 4) of seven patients; 2. the physician was notified of specified weight gain as ordered for two (Patients #1 and 6) of seven patients and 3. ankle circumference was obtained as ordered for one (Patient #3) of seven patients. 1. Patient #2 A review of the plan of care dated 10/18/21 to 12/16/21 showed orders for the skilled nurse to obtain the patient's weight every visit A review of the electronic medical record showed the following: A skilled nurse assessment dated 11/03/21 showed no documented weight. A skilled nurse assessment dated 11/18/21 showed no documented weight. Patient #4 A review of the plan of care dated 09/16/21 to 11/14/21 showed orders for the skilled nurse to obtain the patient's weight every visit. A skilled nurse assessment dated 09/23/21 showed no documented weight. A skilled nurse assessment dated 09/28/21 showed no documented weight. A skilled nurse assessment dated 10/04/21 showed no documented weight. A skilled nurse assessment dated 10/11/21 showed no documented weight. A skilled nurse assessment dated 10/18/21 showed no documented weight. A skilled nurse assessment dated 10/25/21 showed no documented weight. A skilled nurse assessment dated 11/01/21 showed no documented weight. A skilled nurse assessment dated 11/12/21 showed no documented weight. 2. Patient #1 A review of the plan of care dated 09/04/21 to 11/02/21 showed orders for the skilled nurse to notify the physician of a weight gain or loss of 5 pounds. A review of the electronic medical record showed the following: A skilled nurse assessment dated 09/14/21 showed a weight of 170 pounds. A skilled nurse assessment dated 09/21/21 showed a weight of 182 pounds (a 12-pound weight gain since the last obtained weight) with no physician notification of the weight gain. Patient #6 A review of the plan of care dated 08/12/21 to 10/10/21 showed orders for the skilled nurse to notify the physician of a weight gain or loss of 5 pounds. A review of the electronic medical record showed the following: A skilled nurse assessment dated 08/19/21 showed a weight of 340 pounds. A skilled nurse assessment dated 08/26/21 showed a weight of 345 pounds (a five-pound weight gain since the last obtained weight) with no physician notification of the weight gain. A skilled nurse assessment dated 09/09/21 showed a weight of 355 pounds (a ten-pound weight gain since the last obtained weight) with no physician notification of the weight gain. A skilled nurse assessment dated 09/16/21 showed a weight of 350 pounds (a five-pound weight loss since the last obtained weight) with no physician notification of the weight loss. A skilled nurse assessment dated 09/23/21 showed a weight of 345 pounds (a five-pound weight loss since the last obtained weight) with no physician notification of the weight loss. A skilled nurse assessment dated 09/30/21 showed a weight of 345 pounds. A skilled nurse assessment dated 10/08/21 showed a weight of 360 pounds (a fifteen-pound weight gain since the last obtained weight) with no physician notification of the weight gain. Patient #3 A review of the plan of care dated 09/07/21 to 11/05/21 showed orders for the skilled nurse to obtain the patient's ankle circumference every visit. A review of the electronic medical record showed the following: A skilled nurse assessment dated 09/10/21 showed no documented ankle circumference. A skilled nurse assessment dated 09/15/21 showed no documented ankle circumference. A skilled nurse assessment dated 09/22/21 showed no documented ankle circumference. On 12/16/21 at 11:10 am, Staff E stated: 1. the weights should have been obtained as ordered for Patients #2 and 4; 2. the physician should have been notified of the weight gains for Patients #1 and 6; and 3. the ankle circumference should have been obtained for Patient #3.

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 ensure physician notification of significant weight gain for two (Patient #1 and 6) of seven patients. Patient #1 A review of the plan of care dated 09/04/21 to 11/02/21 showed a secondary diagnosis of hypertensive heart disease with heart failure and orders for the skilled nurse to notify the physician of a weight gain or loss of 5 pounds. A review of the electronic medical record showed the following: A skilled nurse assessment dated 09/14/21 showed a weight of 170 pounds. A skilled nurse assessment dated 09/21/21 showed a weight of 182 pounds (a 12-pound weight gain since the last obtained weight) with no physician notification of the weight gain. Patient #6 A review of the plan of care dated 08/12/21 to 10/10/21 showed a secondary diagnosis of hypertensive heart disease with heart failure and orders for the skilled nurse to notify the physician of a weight gain or loss of 5 pounds. A review of the electronic medical record showed the following: A skilled nurse assessment dated 09/30/21 showed a weight of 345 pounds. A skilled nurse assessment dated 10/08/21 showed a weight of 360 pounds (a fifteen-pound weight gain since the last obtained weight) with no physician notification of the weight gain On 12/16/21 at 11:15 am, Staff E stated the physician should have been notified of the weight gains for Patients #1 and 6.