Every finding on record at Mays Professional Home Health of Sallisaw, LLC

The Oklahoma State Department of Health conducted an unannounced Emergency Preparedness Program survey at the agency on 12/16/25 to 12/18/25. 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 on 12/16/25 to 12/18/25. An entrance conference was conducted with RN1. The survey process was explained. Questions were answered. RN1 was identified as the contact person for administrative issues and the contact person for clinical issues. Findings were discussed during an informal exit conference with RN1 and Administrative staff. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: RN Registered Nurse SN Skilled Nurse POC Plan of Care SOC Start of Care HHA Home Health Aide SAV Supervisory Aide Visit

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 SN staff failed to promptly alert the physician the need to alter the plan of care based on patient specific needs assessed for one (#5) of thirteen (#1 - #13) records reviewed. Patient #5: Review of Patient #5 record for SOC certification period 11/04/25 to 01/02/26 showed a primary diagnosis of Hypertensive Heart Disease with Chronic Kidney Disease with Heart Failure and a secondary diagnosis of Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease. Further review of Physician orders included SN visits 1 time a week for 9 weeks and "SN to monitor patient log of glucose reading for abnormalities and report out of range findings prn to PCP". Blood glucose parameters specified "Fasting BS 150 mg/dl or Random BS 200 mg/dl". SN Visit Notes for 11/11/25, 11/17/25,11/25/25, 12/2/25, and 12/09/25 documented the patient does not check blood sugar and her daughter states patient is not a diabetic. No diabetic medications were identified on the current Client Medication Report. During a home visit on 12/17/25 at 3:00 PM, the daughter informed this Surveyor the patient was not a diabetic and they do not routinely check her blood sugar. The daughter stated the physician had discontinued medications several years ago because the patient's blood sugar was within normal range without medications. The daughter stated she did not know why they still have her as a diabetic. During an interview on 12/18/25 at 9:15 AM, RN1 stated there was no evidence the SN notified the physician the patient and daughter were not checking blood sugars as indicated on the plan of care and the need to alter the plan of care for Patient #5.

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 RN staff failed to conduct an onsite supervisory visit of the Home Health Aide at least every 14 days for one (#3) of two (#3 and #9) records reviewed with orders for Home Health Aide services. Patient #3: Review of Patient #3 record for recertification period 12/04/25 to 02/01/26 showed a diagnosis of Essential Hypertension and orders for SN visits 1 time a week for 8 weeks and Home Health Aide (HHA) visits 1 time a week for 1 week and 2 times a week for 8 weeks. Further review of RN visits failed to provide evidence an HHA Supervisory Visit (SAV) was conducted as required on 11/04/25, a RN SAV was conducted 12/03/25 (1 day late) and no additional RN SAV was documented as of the time of this survey. During an interview on 12/18/25 at 9:15 AM, RN1 stated the RN staff failed to conduct onsite HHA Supervisory Visits at least every 14 days as required for Patient #3.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/08/22 to 11/09/22. 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 11/08/22 to 11/09/22. An entrance conference was conducted with Staff A. 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, H and I. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: ABN advance beneficiary notice PT physical therapy POC plan of care 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 prior to being discharged from the agency for two (Patients #8 and #10) of 10 patients. Findings: Patient #8 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency for change in payer source on 05/27/22. On 11/09/22 at 11:55 a.m., Staff A stated there was no ABN notice in the clinical record for Patients #8. Patient #10 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency for non-compliance on 07/26/22. On 11/09/22 at 11:55 a.m., Staff A stated: 1. There was no ABN notice in the clinical record for Patients #10 and; 2. Patient #10 should have received an ABN notice prior to being discharged from the agency.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Show documentation of the problems encountered by the agency related to behaviors that impeded the agency from providing care and services for one (Patient #10) of 10 patients; 2. Educate the patient on potential health outcomes from discontinued agency care and services for one (Patient #10) of 10 patients; 3. Notify the physician of the patient's behaviors that impeded the agency from providing care and services for one (Patient #10) of 10 patients. Findings: Patient #10 A review of SN visit notes and coordination/communication notes from 06/21/22 and 07/26/22 during episode of 06/21/22 to 08/19/22 documented no identified problems encountered by the agency related to behaviors that impeded the agency from providing care and services, no communication or education attempts to the patient for potential health outcomes resulting from discontinued agency care and services, and no physician notification of the patient's behaviors that impeded the agency from providing care and services. Documentation showed the patient was discharged from agency services for non-compliance on 07/26/22. On 11/09/22 at 12:00 p.m., Staff A stated there was no documentation of: 1. Problems encountered by the agency related to behaviors that impeded the agency from providing care and services; 2. Patient education of potential health outcomes from discontinued agency care and services; 3. Physician notification of the patient's behaviors that impeded the agency from providing care and services for patient #10.

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 the individualized patient POCs included recurring urinary catheter change treatment intervention due dates were documented for two (Patients #5 and #7) of 10 patients. Findings: Patient #5 A review of the plan of care dated 09/28/22 to 11/26/22 documented a principal diagnosis of stage 3 pressure ulcer and showed orders for SN to change indwelling urinary catheter every month. POC documentation showed no treatment intervention date the indwelling urinary catheter change was due or last completed. On 11/09/22 at 11:40 a.m., Staff A stated recurring urinary catheter treatment intervention change due dates and/or last change dates should have been documented in the POC for patient #5. Patient #7 A review of the plan of care dated 08/22/22 to 10/20/22 documented a principal diagnosis of cerebral infarction and showed orders for SN to manage and change indwelling urinary catheter every month and SN to administer bladder irrigation with 30 milliliters of sterile normal saline every two weeks. POC documentation showed no treatment date the indwelling urinary catheter change was due or last completed and no treatment intervention due date for the bladder irrigation. On 11/08/22 at 11:45 a.m., Staff A stated recurring urinary catheter change treatment intervention due dates and/or last change dates and the treatment intervention due dates for the bladder irrigation administration should have been documented in the POC for patient #7.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT 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 #5) of 10 patients. Findings: Patient #3 A review of a plan of care dated 09/27/22 to 11/25/22 documented a primary diagnosis of stage 2 pressure ulcer and showed orders for SN to perform wound site assessment and perform wound site care every visit. Documentation showed SN visit note dated 10/25/22 documented the wound site was closed; SN visit note dated 11/01/22 stated the wound site was non-blanching. Documentation showed no physician coordination of care communications of changes to the wound site and showed no changes in orders. On 11/09/22 at 11:35 a.m., Staff A stated the agency failed to notify the physician of changes in the wound status and obtain orders to update the POC for patient #3. Patient #5 A review of the plan of care dated 09/28/22 to 11/26/22 documented a principal diagnosis of stage 3 pressure ulcer and showed orders for SN to: change indwelling urinary catheter every month, assess and teach intervention to manage diabetic foot care, pain, falls and pressure ulcer prevention; obtain weight or obtain ankle circumference measurements every visit and report to MD weight gain or loss of five pounds or increase in ankle circumference measurements; perform fasting/random blood sugar analysis each visit and report findings to MD outside of reporting parameters of less than 70 and greater than 250; monitor patient log of glucose readings for abnormalities. A review of a SN visit note dated 09/30/22 documented the patient did not monitor his blood sugar levels; and SN visit notes dated 09/30/22, 10/03/22, 10/06/22, 10/07/22, 10/12/22, 10/14/22, 10/21/22, 10/28/22, 10/30/22, and10/31/22 documented the SN was ‘unable to observe’ the patient’s weight and showed no ankle circumference measurements. A review of an episode coordination note read as follows: On 10/14/22 a visit note recommendation to amend SN visit note’s dated 09/20/22, 09/30/22, 10/03/22, 10/05/22 and 10/07/22 a patient weight of 220 pounds for each visit. On 10/17/22 a visit note addendum documented, “on SN visits dated 09/20/22, 09/30/22, 10/03/22, 10/05/22 and on 10/07/22 the patient’s weight is 220 pounds for each visit listed” (the SN notes dated 09/30/22, 10/03/22, 10/06/22, 10/07/22, 10/12/22, 10/14/22, 10/21/22, 10/28/22, 10/30/22 and on 10/31/22 documented the SN was ‘unable to observe’ the patient’s weight and showed no ankle circumference measurements). Documentation showed no physician coordination of care communications from 09/30/22 to 10/31/22 to inform the physician of no patient weight monitoring or ankle circumference measurements, patient refusal of blood sugar monitoring and no changes in orders. On 11/09/22 at 11:40 a.m., Staff A stated: 1. The physician for patient #5 should have been informed the patient refused to continue monitoring blood glucose levels and; 2. The SN had not obtained patient #5’s weight or ankle circumference measurements during SN visits conducted on 09/30/22, 10/03/22, 10/06/22, 10/07/22, 10/12/22, 10/14/22, 10/21/22, 10/28/22, 10/30/22 and on 10/31/22.