Mays Home Health of NC Ok

“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 interview, the agency failed to ensure: 1. the physician was notified of fasting blood sugar levels outside of ordered parameters for one (Patient #1) of 9 patients; 2. wound measurements were used to assess and observe the patient wounds as ordered for one (Patient #2) of 9 patients; and 3. the physician was notified of systolic blood pressure readings outside of ordered parameters for one (Patient #5) of 9 patients. Patient #1 A review of the plan of care dated10/24/23 to 12/22/23 showed a primary diagnosis of type II diabetes mellitus and documented the physician be notified of fasting blood glucose levels greater than 140. A review of the clinical record showed the following: A skilled nurse assessment dated 10/31/23 showed a fasting blood glucose level of 143 and documented the physician was not notified. A skilled nurse assessment dated 11/07/23 showed a fasting blood glucose level of 173 and documented the physician was not notified. A skilled nurse assessment dated 11/14/23 showed a fasting blood glucose level of 173 and documented the physician was not notified. A skilled nurse assessment dated 11/21/23 showed a fasting blood glucose level of 264 and documented the physician was not notified. A skilled nurse assessment dated 11/28/23 showed a fasting blood glucose level of 178 and documented the physician was not notified. A skilled nurse assessment dated 12/05/23 showed a fasting blood glucose level of 234 and documented the physician was not notified. Patient #2 A plan of care dated 10/10/23 to 12/08/23 showed a primary diagnosis of pressure ulcer to the left buttock stage IV with a skilled nurse frequency of two visits per week for nine weeks and documented the skilled nurse to assess and observe the wound during each visit. A skilled nurse visit dated 11/08/23 documented no wound measurements due to “not due”. A skilled nurse visit dated 11/13/23 documented no wound measurements due to “not due”. A skilled nurse visit dated 11/17/23 documented no wound measurements due to “not due”. A skilled nurse visit dated 12/01/23 documented no wound measurements due to “not due”. A skilled nurse visit dated 12/06/23 documented no wound measurements due to “not due”. A skilled nurse visit dated 12/08/23 documented no wound measurements due to “not due”. Patient #5 A review of the plan of care dated 11/10/23 to 01/08/24 showed a primary diagnosis of congestive heart failure and a skilled nurse frequency of on visit per week for 10 weeks and documented the physician was to be notified of a systolic blood pressure greater than 140. A review of the clinical record showed the following; A skilled nurse assessment dated 11/10/23 documented a systolic blood pressure of 148 and the physician was not notified. A skilled nurse assessment dated 11/17/23 documented a systolic blood pressure of 144 and the physician was not notified. A skilled nurse assessment dated 11/24/23 documented a systolic blood pressure of 164 and the physician was not notified. A skilled nurse assessment dated 11/29/23 documented a systolic blood pressure of 165 and the physician was not notified. A skilled nurse assessment dated 12/06/23 documented a systolic blood pressure of 152 and the physician was not notified. A skilled nurse assessment dated 12/11/23 documented a systolic blood pressure of 141 and the physician was not notified. On 01/17/24 at 5:30 pm, Staff B stated: 1. the physician was not notified of fasting blood sugar reading outside of the ordered parameters for Patient #1; 2. the skilled nurse did not obtain wound measurements to properly assess the wound as ordered for Patient #2; and 3. the physician was not notified of the systolic blood pressure readings outside of ordered parameters for Patient #5.”

“Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aide supervisory visits were completed every 14 days for one (Patient #5) of 9 patients. Patient #5 A plan of care dated 11/10/23 to 01/08/24 ordered home health aide visits twice per week for eight weeks. A review of the clinical record showed the following: A home health aide visit was performed on 11/22/23 for the week of 11/19/23 to 11/25/23. A home health aide visit was performed on 11/29/23 for the week of 11/26/23 to 12/02/23. A home health aide visit was performed on 12/06/23 for the week of 12/03/23 to 12/09/23. A home health aide visit was performed on 12/13/23 for the week of 12/10/23 to 12/16/23. A home health aide visit was performed on 12/20/23 for the week of 12/17/23 to 12/23/23. A home health aide visit was performed on 12/28/23 for the week of 12/24/23 to 12//30/23. A skilled nurse assessment dated 12/29/23 documented supervisory aide visit was conducted. No supervisory aide visits were conducted prior to this assessment (29 days with no supervisory aide visit performed). On 01/17/24 at 3:45 pm, Staff B stated supervisory aide visits exceeded 14 days for Patient #5.”

“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 hospice failed to ensure the plan of care was fully developed to include individualized interventions in relation to the primary diagnosis for seven (Patients #1, 3, 4, 5 and 6) of 9 patients reviewed. Patient #1 A review of the plan of care dated10/24/23 to 12/22/23 showed a primary diagnosis of type II diabetes mellitus and showed no patient specific interventions for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 10/01/23 to 11/29/23 showed a primary diagnosis of non-infective gastroenteritis and colitis and showed no patient specific interventions for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 11/24/23 to 01/22/24 showed a primary diagnosis of malignant neoplasm of prostate and showed no patient specific interventions for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 11/10/23 to 01/08/24 showed a primary diagnosis of congestive heart failure and showed no patient specific interventions for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 11/29/23 to 01/27/24 showed a primary diagnosis of urinary tract infection and showed no patient specific interventions for the management of the primary diagnosis. On 01/17/24 at 3:30 pm, Staff B stated there were no patient specific interventions for the primary diagnosis for Patients #1, 3, 4, 5 and 6.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to update the plan of care to reflect the status of the patient for one (Patient #3) of 9 patients. Patient #3 A review of the plan of care dated 10/01/23 to 11/29/23 which showed orders for the skilled nurse to obtain the patient’s weight each visit and documented a skilled nurse frequency of one visit per week for nine weeks. A review of the clinical records showed the following; A skilled nurse visit dated 10/10/23 documented no weight. A coordination note dated 10/10/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. A skilled nurse visit dated 10/17/23 documented no weight. A coordination note dated 10/17/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. A skilled nurse visit dated 10/24/23 documented no weight. A coordination note dated 10/24/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. A skilled nurse visit dated 10/31/23 documented no weight. A coordination note dated 10/31/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. A skilled nurse visit dated 11/07/23 documented no weight. A coordination note dated 11/07/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. A skilled nurse visit dated 11/14/23 documented no weight. A coordination note dated 11/14/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. A skilled nurse visit dated 11/21/23 documented no weight. A coordination note dated 11/21/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. A skilled nurse visit dated 11/28/23 documented no weight. A coordination note dated 11/28/23 documented a clinical exception due to the patient not being able to stand. No update was made to the patient plan of care. On 01/17/24 at 3:40 pm, Staff B stated the plan of care for Patient #3 should have been updated to reflect the inability to stand for weights during each skilled nurse visit.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of a significant weight change for one (Patient #7) of 9 patients. Patient #7 A plan of care dated 09/12/23 to 11/10/23 showed a diagnosis of pneumonitis due to inhalation of food and vomit with a skilled nurse frequency of on visit per week for one week and one visit every other week for eight weeks. A review of the clinical record showed the following: A skilled nurse assessment dated 09/12/23 documented a weight of 224 pounds for the week of 09/12/23 to 09/16/23. No skilled nurse visits were performed for the week of 09/17/23 to o09/23/23. A skilled nurse assessment dated 09j/29/23 documented a weight of 203 pounds (a 21-pound weight loss from the previous assessment) for the week of 09/24/23 to 09/30/23. No physician notification was made for the 21-pound weight loss. On 01/17/24 at 4:00 pm, Staff B stated the physician should have been notified of the 21-pound weight loss for Patient #7.”