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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/20/25 - 05/22/25. 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 complaint #111916 at the agency on 05/20/25 - 05/22/25. An entrance conference was conducted with the Staff A, Staff B and Staff C. The survey process was explained. Questions were answered. The Staff B was identified as the contact person for administrative issues and Staff C was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, Staff B, Staff C and other administrative staff. Deficiencies were cited as a result of the Medicare re-certification survey. No deficiencies were cited related the complaint. Glossary: SN Skilled Nurse OT Occupational Therapy SOC Start of Care POC Plan of Care ROC Resumption of Care EMR Electronic Medical Record

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 observation, record review and interviews, the agency failed to provide an individualized POC to include patient specific interventions and safety measures based on the assessed needs of each patient for three (#2, #3 and #5) of ten (#1 - 10) records reviewed. This deficient practice had the potential to prevent the patients progress towards goals and failure to protect patients from injury. Patient #2 Review of the current recertification POC dated 04/10/25 - 06/08/25 included a primary diagnosis of Chronic Venous Hypertension with Ulcer and secondary diagnosis of Type 2 Diabetes Mellitus with Chronic Kidney Disease. Orders included, "SN for instructions/reinforcement of diabetic care to include diet, skin care, administration of insulin, blood glucose testing and diabetic foot care" and "SN to perform fasting /random blood sugar analysis PRN S/SX (Signs and Symptoms) of hypo/hyperglycemia and report findings FSBS 200 mg/dl or random BS 250 mg/dl to PCP. SN to monitor patient log of glucose reading for abnormalities". During a home observation visit on 05/21/25 at 9:00 AM, the SN was observed obtaining a random blood glucose reading with the result of "107". When this Surveyor asked the patient how often she checks her blood sugar, Patient #2 stated, " I don't, I don't have diabetes, and I don't have a machine". Further review of the POC failed to identify any diabetic supplies and no diabetic medications were identified on the Client Medication Record. The Vital Signs Report and SN Visit Notes for the current episode failed to provide evidence of blood glucose testing by the patient or monitoring by the SN as ordered. There was no evidence the physician was notified of the patient's noncompliance with blood sugar testing. Patient #3 Review of the current recertification POC dated 03/23/25 - 05/21/25 showed diagnosis of Immunoglobulin G deficiency, chronic respiratory failure and dependence on supplemental oxygen with a history of nicotine dependance. The Client Medication Report included Oxygen to administer at 2-3 liters/ per minute continuous and may administer up to 5 L/M as needed for Shortness of Breath. The POC included oxygen supplies, but no oxygen safety measures were identified on the POC. During a home observation visit on 05/21/25 at 11:00 AM, Patient #5 was observed sitting in a second-floor room wearing Oxygen per nasal cannula at 3 liters / minute. When asked by this Surveyor if he had extra oxygen tanks, fire extinguisher and smoke detectors, he stated he had a fire extinguisher somewhere but did not know if he had a smoke detector. He stated an extra tank was in another room and he had a tank he kept in his car because it was too heavy for him to carry. The extra tank in the home was observed in a bedroom secured in a cart. There was no 'No Smoking" sign posted, or smoke detectors identified in the home. The SN was not aware of the Oxygen tank stored in the car and confirmed no signs were posted at the home. Patient #5 Review of the initial certification POC dated 03/19/25 - 05/17/25 included a primary diagnosis of Congestive Heart Failure and orders for "SN to provide instructions related to heart failure...SN may collect Calf/Ankle Circumference if unable to obtain weight and notify RN/MD of any increase or decrease of 0.5 CM and O2 <90%". The SN Assessment stated the patient had a breakdown of internal fixation device of ankle requiring the patient to be non-weight bearing and had a Stage 2 pressure ulcer of the right ankle. The Vital Signs Report indicated the SN staff obtained Calf Circumference and notified the Physician of changes as ordered. ON 03/24/25, Patient #5 was placed on "Hospital Hold" followed by a Resumption of Care (ROC) on 04/18/25. A review of the ROC orders included orders for "SN to provide instructions related to heart failure... SN to collect WT (weight) / O2 Q (every) visit. SN to report weight gain of 3 lbs. in one day or 5 lbs. in 1 week and O2 <90%". The SN assessment at ROC stated Patient #5 was non-weight bearing. Review of the Vital Signs Report indicated SN staff continued to obtained Calf Circumferences each visit. No weights were obtained as ordered at the ROC. During an interview on 05/22/25 at 09:45 AM, Staff C stated the POC for Patients' #2, #3 and #5 were not individualized based on the patents needs assessed by the SN.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview the Agency failed to incorporate clinical note documentation into the Electronic Medical Record (EMR) for one (#5) of ten (#1 -10) records reviewed. This deficient practice had the potential to prevent effective care coordination among disciplines. Patient #5 Review of referral documents for initial certification period 03/19/25 to 05/17/25, included an order for SN and OT services. Further record review failed to provide evidence of an OT evaluation or services and no documentation as to the reason OT services were not provided. During an interview on 05/22/25 at 9:40 AM, Staff C stated the OT evaluation was not completed as patient #5 was placed on "Hospital Hold" 03/24/25. Staff C confirmed OT documentation of the attempted or delayed evaluation was not incorporated into the EMR a required.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 07/06/22 to 07/07/22. 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 complaint #OK00049350 investigation at the agency on 07/06/22 through 07/07/22. An entrance conference was conducted with Staff A, B and C. The survey process was explained. Questions were answered. Staff A and Staff B were identified as the contact persons for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A, B, C, D, E, F, G and H. Standard level deficiencies were cited as a result of the Medicare re-certification survey. No deficiencies were cited related to the complaint. Glossary: CHHA Certified Home Health Aide POC Plan of Care SN Skilled Nurse

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD 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 (Patient #3 and #6) of 13 patients. Findings: Patient #3 A review of a plan of care dated 06/23/22 to 08/21/22 documented a primary diagnosis of Diabetes Mellitus Type II with foot ulcer and showed a physician reporting parameter of fasting blood sugar of less than 70 and greater than 200 and a random blood sugar of less than 70 and greater than 250. Documentation showed SN visit notes dated 06/25/22, 06/28/22 and on 07/01/22 showed no blood sugar levels monitored due to no patient glucometer equipment. Documentation showed no physician coordination of care communications for the patient having no blood glucose monitoring equipment and no changes in orders. Patient #6 A review of a plan of care dated 05/23/22 to 07/21/22 documented a primary diagnosis of pressure ulcer to the right heel and a secondary diagnosis of Diabetes Mellitus Type II with peripheral angiopathy and showed a physician reporting parameter of fasting blood sugar of less than 70 and greater than 250 and a random blood sugar of less than 70 and greater than 300. Documentation showed a SN visit note dated 05/23/22 showed a blood sugar level of 313; and on 06/24/22 a blood sugar level of 454. Documentation showed vital sign alerts were systematically auto faxed to the physician office with no follow up confirmation of receipt of communications, no direct physician coordination of care communications as follow up to the changes in the patient’s blood sugar levels and no changes in orders. On 07/07/22 at 12:15 p.m., Staff A stated: The physician for Patient #3 should have been informed the patient had no glucose monitoring equipment to continue monitoring blood glucose levels but was not and;The blood glucose levels for Patient #6 should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in blood sugar levels but had none.

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 on the POC’s for: SN to conduct assessment of patient oxygen saturation rate percentage every visit and notify the physician of change in patient oxygen saturation rate percentage outside of reporting parameters for one (Patient #1) of 13 patients;SN to conduct assessment and perform wound care to wound site every visit for one (Patient #3) of 13 patients;SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight outside of reporting parameters for two (Patient #5 and #8) of 13 patients;SN to conduct assessment of patient blood sugar and perform finger stick blood sugar as needed every visit and notify the physician of blood sugar level outside of reporting parameters for one (Patient #5) of 13 patients;SN to conduct visit frequency as ordered by the physician for two (Patient #6 and #7) of 13 patients. Findings: Patient #1 A review of the POC dated 06/03/22 to 08/01/22 showed orders for SN to conduct assessment of patient oxygen saturation rate percentage every visit and notify the physician of change in patient oxygen saturation rate percentage less than 90%. Documentation showed during SN visit conducted on 06/17/22, no oxygen saturation rate was monitored. Documentation showed no patient/caregiver refusal of oxygen saturation rate monitoring, no physician notification and no change in orders. Patient #3 A review of the POC dated 06/23/22 to 08/21/22 showed orders for SN to conduct assessment and perform wound care to wound site every visit. Documentation showed during SN visits conducted on 06/23/22, 06/28/22 and 07/01/22 no wound care was performed during the SN visits. Documentation showed no patient/caregiver refusal of wound site assessment and care, no physician notification and no change in orders. Patient #5 A review of the POC dated 04/28/22 to 06/28/22 showed orders for SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight outside of reporting parameters and; conduct assessment of patient blood sugar and perform finger stick blood sugar as needed every visit and notify the physician of blood sugar level outside of reporting parameters. Documentation showed during SN visits conducted on 05/12/22, 05/19/22, 05/24/22 and on 06/08/22 no patient weight measurements were obtained. During SN visit conducted on 06/08/22 no blood sugar monitoring was completed. Documentation showed no patient/caregiver refusal of weight monitoring or blood sugar monitoring, no physician notification and no change in orders. Patient #6 A review of the POC dated 05/23/22 to 07/21/22 showed orders for SN visit frequency of three times a week for four weeks then one time a week for one week and one every two weeks for four weeks. During the week of 06/05/22 to 06/11/22 SN visits were conducted on 06/06/22, 06/08/22 and on 06/10/22 three visits conducted, four visits ordered). Documentation showed no attempts to conduct the fourth ordered visit, no patient/caregiver refusal of the visit, no physician notification and no change in orders. Patient #7 A review of the POC dated 06/14/22 to 08/12/22 showed orders for SN visit frequency of two times a week for one week then four times a week for one week then one time a week for three weeks and one every two weeks for four weeks. During the week of 06/26/22 to 07/02/22 SN visits were conducted on 06/27/22 and on 07/01/22 (two visits conducted, one visit ordered). Documentation showed no patient/caregiver request of an extra visit, no physician notification and no change in orders. Patient #8 A review of the POC dated 05/26/22 to 07/24/22 showed orders for SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight outside of reporting parameters or conduct assessment of patient ankle circumference every visit and notify the physician of measurements outside of reporting parameters. Documentation showed during SN visits conducted on 05/27/22 and on 06/08/22 no patient weight measurements and/or ankle circumference measurements were obtained. Documentation showed no patient/caregiver refusal of weight monitoring or ankle circumference measurements, no physician notification and no change in orders. On 07/07/22 at 12:10 p.m., Staff A stated: SN should have conducted assessment of patient oxygen saturation rate percentage every visit for Patient #1 but did not;SN should have conducted assessment and performed wound care to wound site every visit for Patient #3 but did not;SN should have conducted assessment of patient weight every visit or alternatively measured the patient ankle circumferences for Patient #5 and #8 but did not;SN should have conducted assessment of patient blood sugar and perform finger stick blood sugar as needed every visit for Patient #5 and but did not;SN should have conducted visit frequencies as ordered by the physician for Patient #6 and #7 but did not.

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 interview, the agency failed to ensure completed transfer/discharge summaries were provided for five (Patients #6, 10, 11, 12 and #13) of 13 patients. Findings: Patient #6 A review of the clinical record documented transfer from the agency on 05/31/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. Patient #10 A review of the clinical record documented transfer from the agency on 04/01/22 to in-patient hospital provider services with subsequent discharge to hospice provider services on 04/03/22. Documentation showed no transfer summary was provided to the in-patient hospital service provider nor was a discharge summary provided to the hospice service provider. Patient #11 A review of the clinical record documented transfer from the agency on 03/22/22 to in-patient hospital provider services. Documentation showed no transfer summary was provided to the in-patient hospital service provider. Patient #12 A review of the clinical record documented transfers from the agency on 06/07/22, 06/13/22 and on 06/21/22 to in-patient hospital provider services. Documentation showed no transfer summaries were provided to the in-patient hospital service providers. Patient #13 A review of the clinical record documented discharge from the agency on 06/27/22 to in-patient SNF provider services. Documentation showed no discharge summary was provided to the in-patient SNF service provider. On 07/07/22 at 12:05 p.m., Staff A stated no transfer/discharge summaries were provided to the receiving service providers for Patients #6, 10, 11, 12 and #13.