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

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 03/25/25 to 03/27/25. 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 at the agency from 03/25/25 to 03/27/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as a contact person 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 survey. Glossary: ABN advance beneficiary notice CHHA certified home health aide HHA Home Health Agency HHCOC home health change of care OT occupational therapy POC Plan of Care SN skilled nurse SOC start of care

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 advance beneficiary notice and or HHCOC notice was provided to a patient prior to discharge from agency services for one (Patient #12) of 12 patients. Findings: Patient #12 A review of the clinical record showed a SOC date of 02/23/24. Documentation showed an OT discipline discharge for no authorization of service from the insurance payor source on 10/21/24. Documentation showed no home health change of care notice was provided to the patient. Documentation showed the patient was discharged from agency services on 12/18/24 for no authorization of services from the insurance payor source. Documentation showed no advance notice of discharge was provided to the patient prior to discharge from the agency. On 03/27/25 at 11:00 a.m., Staff A stated: 1. There were no ABN or HHCOC notices in the clinical record. 2. Patient #12 should have received HHCOC notice when OT discipline discharged and an ABN notice prior to being discharged from agency services.

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 a SOC assessment was conducted within 48 hours of referral for two (Patients #3 and #4) of 12 patients. Findings: Patient #3 A review of the clinical record showed the agency received referral information on 07/23/24 and the SOC assessment occurred on 08/08/24 (16 days later). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 03/27/21 at 10:20 a.m., Staff A stated the SOC assessment should have been conducted within 48 hours of referral. Patient #4 A review of the clinical record showed the agency received referral information on 01/23/24 and the SOC assessment occurred on 01/26/24 (3 days later). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 03/27/21 at 10:25 a.m., Staff A stated the SOC assessment should have been conducted within 48 hours of referral.

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: 1. SN reported to the physician patient pain levels outside of reporting parameters for one (Patients #1) of 12 patients. 2. SN provided visits as ordered on the POC for four (Patients #2, 9, 10 and #12) of 12 patients. 3. SN reported to the physician weight readings outside of reporting parameters for two (Patients #5 and #12) of 12 patients. 4. CHHA provided visits as ordered on the POC for three (Patients #5, 10 and #12) of 12 patients. 5. SN utilized the size of urinary catheter ordered on the POC for urinary catheter management intervention for one (Patient #7) of 12 patients. SN reported to the physician blood pressure readings outside of reporting parameters for one (Patient #10) of 12 patients. Findings: Patient #1 A review of the POC dated 02/12/25 to 04/12/25 showed orders for SN to conduct assessment and monitoring of patient pain level every visit and report to the physician reading outside of the reporting parameter greater than 7 of 10. SN visit documentation on 02/13/25 showed a patient reported pain level of 9 of 10. Documentation showed no physician notifications and no change in orders. On 03/27/25 at 10:10 a.m., Staff A stated the SN should have reported the patients’ pain level during the SN visit. Patient #2 A review of the POC dated 02/20/25 to 04/20/25 showed orders for SN visit frequency of one time a week for eight weeks. SN visit documentation on 03/14/25 and 03/21/25 showed the visits were not conducted. Documentation showed no attempts to make up the visits, no physician notifications and no change in orders. On 03/27/25 at 10:15 a.m., Staff A stated the SN should have attempted to make up the ordered visits and notified the physician the patient missed two weeks of the ordered frequency and duration of SN care during the certification period. Patient #5 A review of the POC dated 01/25/25 to 03/25/25 showed orders for SN to conduct assessment and monitoring of patient weight every visit and report to the physician reading outside of the reporting parameter less than 213 pounds or greater than 223 pounds and showed a CHHA visit frequency of two times a week for eight weeks. Documentation showed no CHHA visits during the weeks of 01/26/25 to 02/01/25 (two visits ordered, no visits conducted) and showed no assessment of the patient’s weight during SN visits conducted on 02/05/25, 02/19/25 and on 03/05/25. Documentation showed no physician notifications and no change in orders. On 03/27/25 at 10:30 a.m., Staff A stated the CHHA should have conducted the visits as ordered and the SN should have assessed the patient’s weight during each SN visit. Patient #7 A review of the POC dated 02/01/25 to 04/01/25 showed orders for SN to perform urinary suprapubic catheter change intervention using an 18 French/10-millimeter foley catheter every month. SN visit documentation showed the suprapubic foley catheter was changed on 02/15/25 and 03/18/25 using a 16 French/10-millimeter foley catheter. Documentation showed no physician notifications of size of catheter and showed no change in orders. On 03/27/25 at 10:35 a.m., Staff A stated the SN should have used the foley catheter size ordered in the POC or notified the physician and obtained orders for a different size of catheter. Patient #9 A review of the POC dated 01/18/25 to 03/18/25 showed orders for SN visit frequency of once a week for nine weeks. SN visit documentation during the week of 01/19/25 to 01/25/25 showed no SN visit was conducted (one visit ordered, no visit conducted). Documentation showed no attempts to make up the visit, no physician notification and no change in orders. On 03/27/25 at 10:15 a.m., Staff A stated the SN should have attempted to make up the ordered visit and notified the physician of the missed SN visit. Patient #10 A review of the POC dated 01/07/25 to 03/07/25 showed orders for SN visit frequency of one time a week for one week, three times a week for three weeks, two times a week for one week, then one time a week for four weeks for SN to conduct assessment and monitoring of patient blood pressure every visit and report to the physician reading of diastolic blood pressure greater than 90. Documentation showed during the week 01/12/25 to 01/18/25 SN visits were conducted on 01/13/25 and 01/15/25 (three visits ordered, two visits conducted) and 01/19/25 to 01/25/25 SN visits were conducted on 01/20/25 and on 01/22/25 (three visits ordered, two visits conducted). During SN visit conducted on 01/15/25 documentation showed a diastolic blood pressure reading of 95. Documentation showed no patient refusal of visits, no physician notifications and no change in orders. On 03/27/25 at 10:42 a.m., Staff A stated the SN should have notified the physician of the missed SN visits and of the blood pressure reading from the SN visit dated 01/15/25. Patient #12 A review of the POC dated 10/20/24 to 12/18/24 showed orders for SN visit frequency of once a week for nine weeks for SN to assess, monitor and report weight less than 121 pounds and CHHA visit frequency of two times a week eight weeks. SN visit documentation during the week of 10/27/24 to 11/02/24 showed no SN visit was conducted (one visit ordered, no visit conducted) and no CHHA visits were conducted (two visits ordered, no visits conducted). SN visit documentation dated 11/23/24 showed a patient weight of 117 pounds. Documentation showed no attempts to make up the visits, no physician notification of missed visits or patient weight less than 121 pounds and showed no change in orders. On 03/27/25 at 10:15 a.m., Staff A stated the SN should have attempted to make up the ordered visits for SN and CHHA and notified the physician of the missed visits and patient weight less than 121 pounds.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for three (Patients #5, 11, and #12) of 12 patients. Findings: Patient #5 A plan of care dated 01/25/25 to 03/25/25 showed a CHHA visit frequency of two times a week for eight weeks. A review of the clinical record showed CHHA visits completed 02/05/25, 02/07/25, 02/12/25, 02/14/25, 02/21/25, 02/26/25, 02/27/25, 03/05/25, 03/07/25, 03/12/25, 03/14/25, 0319/25 and 03/21/25 with supervisory visits completed on 01/30/25, 02/12/25, 02/25/25 and 03/12/25 (15 days between supervisory visits). Documentation showed no change in orders, patient refusal or physician notification. Patient #11 A plan of care dated 02/02/25 to 04/02/25 showed a CHHA visit frequency of two times a week for eight weeks and then one time a week for one week. A review of the clinical record showed CHHA visits completed 02/04/25, 02/07/25, 02/11/25, 02/14/25, 02/18/25, 02/21/25, 02/25/25, 02/28/25, 03/04/25, 03/07/25, 03/11/25, 03/14/25, 03/18/25 and 03/21/25 with supervisory visits completed on 02/13/25 and 02/24/25. Documentation showed no supervisory visits were made from 02/25/25 to 03/21/25 (26 days), and showed no change in orders, patient refusal or physician notification. Patient #12 A plan of care dated 10/20/25 to 12/18/25 showed a CHHA visit frequency of two times a week for eight weeks and then one time a week for one week. A review of the clinical record showed CHHA visits completed on 11/05/24, 11/08/24, 11/12/24, 11/19/24, 11/21/24, 11/26/24, 12/03/24, 12/05/24, 12/10/24, 12/13/24 and 12/17/24 with a supervisory visit completed on 10/15/24, 11/13/24 (26 days) and on 11/29/24 (16 days). Documentation showed no patient refusal or physician notification. On 03/27/25 at 10:30 a.m. to 11:00 a.m., Staff A stated the CHHA supervisory visits for Patients #5, 11, and #12 should have been completed by the SN every 14 days.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/09/22 to 05/11/22. 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 at the agency on 05/09/22 through 05/11/22.An entrance conference was conducted with Admin1 and Staff1. The survey process was explained. Questions were answered.Admin1 was identified as the contact person for administrative and clinical issues.Findings were discussed during an informal exit conference with Admin1, Staff1 and Administrative staff members.Standard level deficiencies were cited as a result of the re-certification survey.GLOSSARY: Admin Administrator SN Skilled Nurse RN Registered Nurse POC Home Health Certification and Plan of Care SOC Start of Care

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 interviews, the agency failed to ensure SN staff obtained weights as ordered on the POC for one (#6) of nine (#1- #3 and #5 - #10) records reviewed with orders for the SN to obtain and monitor weights. A review of the POC for Patient #6 for the certification period of 03/25/22 to 05/23/22 revealed Pt #6 was admitted on 03/25/22 with primary diagnosis of Chronic Kidney Disease with Heart Failure. The POC included orders for the SN to obtain weight every visit and notify RN/MD of weight gain or loss of 5 lbs. A review of the Vital Signs Report and the SOC OASIS note revealed a weight of 182 pounds was obtained by the RN on 03/25/22. Further review of the record indicated on the next SN visit of 03/28/22, no weight was documented due to "no scales" and calf circumference measurements were obtained and documented. No order was identified in the record for the SN staff to obtain calf circumference measurements and there was no evidence the physician was notified that weights were not obtained as ordered on the POC. SN Visit note for 04/04/22 indicated no weights were obtained due to "scales broken" and calf circumference measurements were documented. SN Visit note for 04/11/22 and 04/25/22 documented a weight of 182 with a Vital Sign Alert Comment that the weight was entered incorrectly. SN Visit note for 04/18/22 failed to provide a weight or reason the weight was not obtained as ordered and SN visits notes for 05/02/22 and 05/09/22 failed to provide weights and calf circumference measurements were documented instead. On 05/11/22 at 8:15 AM, Admin1 stated the SN staff failed to obtain weights as ordered in the POC and stated there was no order for calf circumference measurements to be obtained for Patient #6.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure SN staff continually assessed wounds for two (#3 and #4) of three (#1, #4 and #8) records reviewed with orders for wound care. Patient #3 A review of Patient #3 POC for period of 02/27/22 to 06/26/22 revealed a primary diagnosis of Cellulitis of the Right Lower Limb with a secondary diagnosis of Type 2 Diabetes Mellitus and history of a Left Leg Above the Knee Amputation. The POC included orders for SN visits 1 time a week for 8 weeks to provide wound care to the right lower leg. A review of agency Policy # 3-002.1 titled, "On-Going Assessments" provided guidelines for assessments of patients/clients during on-going care. Procedure Item #8 stated, "...An RN will reassess the wound no less often than every 21 days". A review of a report titled "Wound Record Report" revealed the right leg cellulitis wound had previously healed, but was reactivated on 02/04/22 with wound care orders for cleansing and application of Una Boot therapy. Further review of the Wound Record Report and SN Visit Notes indicated the RN assessed the wound on 02/22/22 and the next assessment by the RN was documented on 04/26/22 (9 weeks later). Patient #4 A review of Patient #4 POC for period of 03/21/22 to 05/19/22 revealed Pt #4 was admitted on 01/20/22 with a primary diagnosis of Pressure Ulcer of the Left Hip. The POC included orders for SN visits 3 times a week for 3 weeks to provide wound care per negative pressure device. The wound care orders were revised on 04/20/22 to provide daily wound care after the negative pressure device was discontinued. A review of agency Policy # 3-002.1 titled, "On-Going Assessments" stated at Procedure Item #7, "New or changes in condition of home care situations requiring re-assessment should include:...F. Wound care patients should receive, at a minimum, weekly wound photos and measurements". A review of the Wound Record Report and SN Visit Notes revealed no wound measurements were documented for the weeks of 04/10/22, 04/24/22 and 05/01/22. On 05/11/22 at 8:15 AM, Admin1 stated the RN failed to assess the wound timely for Patient #3 and the SN failed to document wound measurements weekly for Patients #4.