Mays Housecall Home Health of Antlers, LLC

“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.”