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

The Oklahoma Department of Health conducted an unannounced Emergency Preparedness Program survey at the agency on 10/16/23 to 10/18/23. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/16/23 to 10/18/23. An entrance conference was conducted with the Regional Director of Nursing and the Director of Nursing. The survey process was explained. Questions were answered. The Regional Director of Nursing was identified as the contact person for administrative issues and the Director of Nursing was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with the Regional Director of Nursing, Director or Nursing and Administrative team members. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: RN Registered Nurse SN Skilled Nurse PT Physical Therapy POC Plan of Care SOC Start of Care

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Physical Therapist failed to conduct an evaluation as ordered by the physician in a timely manner for one (#2) of four (#2 and #5 - #7) records reviewed with orders for PT evaluation. Patient #2 A review of the POC for Patient #2 for certification periods 09/14/23 to 11/12/23 revealed a primary diagnosis of Radiculopathy Lumbar Region. The referral of 09/13/23 and the POC included orders for "PT to evaluate "... A review of PT Visit Notes revealed the PT Evaluation was conducted 09/26/23 (12 days after SOC) and no documentation was evident as to the reason for delay. On 10/17/23 at 2:30 PM, Regional Director of Nursing stated the PT failed to conduct a timely evaluation as required for Patient #2.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, observations and interview, the SN staff failed to provide a patient specific medication record that identified all medications that the patient was currently taking for two (#1 and #2) of seven (#1- #7) records reviewed. Patient #1 A review of the POC for Patient #1 for certification periods 08/29/23 to 10/27/23 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and a pertinent diagnosis of Dependence on Supplemental Oxygen. A review of the agency document titled "Client Medication Report" included Oxygen at 2 liters continuous and PRN throughout the day for SOB (shortness of breath). During a home observation visit on 10/17/23 at 10:15 AM, Patient #1 stated her Oxygen was to be set at 3 liters since her recent hospitalization. The SN observed the setting on the oxygen concentrator and confirmed the setting of 3 liters. Patient #2 A review of the POC for Patient #2 for certification period 09/14/23 to 11/12/23 revealed a primary diagnosis of Radiculopathy Lumbar Region with a pertinent diagnosis of Dependence on Supplemental Oxygen. A review of the "Client Medication Report" failed to provide orders for oxygen as a current medication. During a home observation visit on 10/17/23 at 9:00 AM, Patient #2 confirmed her use of oxygen and an oxygen concentrator was observed in the home. On 10/17/23 at 2:30 PM, Regional Director of Nursing stated the SN staff failed to maintain a current and accurate medication list for Patients #1 and #2.

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 provide an individualized POC to include all supplies and equipment necessary to meet the patient's assessed needs for four (#2 - #5) of seven (#1- #7) records reviewed. Patient #2 A review of the POC for Patient #2 for certification periods 09/14/23 to 11/12/23 revealed a primary diagnosis of Radiculopathy Lumbar Region and pertinent diagnosis of Type II Diabetes Mellitus with hyperglycemia and Dependance on Supplemental Oxygen. The POC included orders for "SN to monitor patient log of glucose readings for abnormalities" but failed to include evidence of patient specific diabetic or oxygen supplies and equipment. Patient #3 A review of the POC for Patient #3 for certification period 10/02/23 to 11/30/23 revealed a primary diagnosis of Partial Intestinal Obstruction and a secondary diagnosis of Type II Diabetes Mellitus. The POC included orders for "SN to monitor patient log of glucose readings for abnormalities" but failed to include evidence of patient specific diabetic supplies and equipment. Patient #4 A review of the POC for Patient #4 for certification periods 08/28/23 to 10/26/23 revealed a primary diagnosis of Malignant Neoplasm of Colon and a pertinent diagnosis of Type II Diabetes Mellitus with Neuropathy. The POC included orders for "SN to monitor patient log of glucose readings for abnormalities" but failed to include evidence of patient specific diabetic supplies and equipment. Patient #5 A review of the POC for Patient #5 for re-certification period 09/02/23 to 10/31/23 revealed a primary diagnosis of Type II Diabetes Mellitus with Hyperglycemia. The POC included orders for "SN to monitor patient log of glucose readings for abnormalities" but failed to include evidence of patient specific diabetic supplies and equipment. On 10/17/23 at 2:30 PM, Regional Director of Nursing stated the Agency failed to include patient specific supplies and equipment for on the POC for Patients #2, #3, #4 and #5.

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 SN staff failed to provide services as ordered by the physician in the plan of care for two (#4 and #5) of seven (#1- #7) records reviewed. Patient #4 A review of the POC for Patient #4 for certification periods 08/28/23 to 10/26/23 revealed a primary diagnosis of Malignant Neoplasm of Colon and a pertinent diagnosis of Type II Diabetes Mellitus with Neuropathy. The POC included orders for "SN to obtain weight every visit and notify RN/MD of weight gain or loss of 5 lbs." and " ....SN to monitor patient log of glucose reading for abnormalities". A review of SN Visit Note for 10/03/23 failed to provide evidence the SN obtained the patients weight or assessed the patient's blood glucose log as ordered. Patient #5 A review of the POC for Patient #5 for re-certification period 09/02/23 to 10/31/23 revealed a primary diagnosis of Type II Diabetes Mellitus with Hyperglycemia. The POC included orders for SN to report fasting BS 150 MG/DL or random BS 250 MD/DL to PCP". A review of SN Visit Note for 09/14/23, 09/21/23 and 10/05/23 failed to provide evidence the SN assessed the patient's blood glucose log as ordered. On 10/17/23 at 2:30 PM, Regional Director of Nursing stated the SN staff failed to assess blood glucose results and weights as ordered on the POC for Patients #4 and #5.