Mays Housecall Home Health of Ada, 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 record review and interview, the agency failed to ensure an individualized plan of care for ten (Patient #1, 2, 3, 4, 6, 7, 8, 9 and 10) of 10 patients. Patient #1 A review of the plan of care dated 08/24/24 to 10/22/24 showed a primary diagnosis of essential (primary) hypertention with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #2 A review of the plan of care dated 07/13/24 to 09/10/24 showed a primary diagnosis of peripheral vascular disease with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #3 A review of the plan of care dated 09/05/24 to 11/03/24 showed a primary diagnosis of chronic kidney disease with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #4 A review of the plan of care dated 09/10/24 to 11/08/24 showed a primary diagnosis of fracture of right shoulder girdle with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #5 A review of the plan of care dated 08/09/24 to 10/07/24 showed a primary diagnosis of pressure ulcer sacral region stage IV with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #6 A review of the plan of care dated 07/27/24 to 09/24/24 showed a primary diagnosis of congestive heart failure with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #7 A review of the plan of care dated 08/16/24 to 10/14/24 showed a primary diagnosis of acute and chronic resp failure with hypoxia with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #8 A review of the plan of care dated 07/19/24 to 09/16/24 showed a primary diagnosis of unspecified atrial fibrillation with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #9 A review of the plan of care dated 09/11/24 to 11/09/24 showed a primary diagnosis of malignant neoplasm of esophagus with no patient specific individualized interventions developed for the management of the primary diagnosis. Patient #10 A review of the plan of care dated 09/26/24 to 11/24/24 showed a primary diagnosis of rectal abscess with no patient specific individualized interventions developed for the management of the primary diagnosis. On 11/06/24 at 12:50 pm, Staff B stated the plan of care for Patients #1, 2, 3, 4, 6, 7, 8, 9 and 10 were not individualized for the patient specific management of the primary diagnosis.”

“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 agency failed to notify the physician of a significant weight change for one (Patient #6) of ten patients. Patient #6 A review of the plan of care dated 07/27/24 to 09/24/24 showed a skilled nurse frequency of one visit per week for nine weeks and documented a diagnosis of congestive heart failure. A review of the clinical record showed the following: A skilled nurse assessment dated 08/01/24 documented a weight of 216 pounds. A skilled nurse assessment dated 08/08/24 documented a weight of 200 pounds (a 16-pound weight loss from the previous assessment). A skilled nurse assessment dated 08.27/24 documented a weight of 200 pounds. A skilled nurse resumption of care assessment dated 08/31/24 documented a weight of 236 pounds (a 36-pound weight increase in four days) with no physician notification of the 36-pound weight increase within the four-day period. A skilled nurse assessment dated 09/05/24 documented a weight of 230 pounds. A skilled nurse assessment dated 09/12/24 documented a weight of 241 pounds (an 11-pound wight increase in seven days) with no physician notification of the 11- pound weight increase within a seven-day period. A skilled nurse assessment dated 09/19/24 documented a weight of 229 pounds (a twelve-pound weight loss in seven days) with no physician notification of the twelve-pound weight decrease within a seven-day period. A skilled nurse assessment dated 09/24024 documented a weight of 236 pounds (a seven-pound weight increase in five days) with no physician notification of the seven-pound weight increase within a five-day period. On 11/06/24 at 1:35 pm., Staff B stated the physican should have been notifed of the significant weight changes for Patient #6.”