Mays Housecall Home Health of Tulsa, LLC

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial evaluation/SOC comprehensive assessment was conducted within 48 hours of referral for four (Patients #3, 4, 5 and #8) of 13 patients. Findings: Patient #3 A review of the clinical record showed the agency received referral information on 09/24/25 and the initial evaluation/SOC assessment occurred on 09/29/24 (5 days). The clinical record showed no patient refusal of initial evaluation/SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #4 A review of the clinical record showed the agency received referral information on 07/29/25 and the initial evaluation/SOC assessment occurred on 08/13/25 (15 days). The clinical record showed no patient refusal of initial evaluation/SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #5 A review of the clinical record showed the agency received referral information on 07/07/25 and the initial evaluation/SOC assessment occurred on 07/10/25 (3 days). The clinical record showed no patient refusal of initial evaluation/SOC assessment, no physician notification of a delay in SOC and no change in orders. Patient #8 A review of the clinical record showed the agency received referral information on 07/26/23 and the initial evaluation/SOC assessment occurred on 07/31/23 (5 days). The clinical record showed no patient refusal of initial evaluation/SOC assessment, no physician notification of a delay in SOC and no change in orders. On 12/04/25 at 10:43 a.m., Staff A stated the initial evaluation/SOC comprehensive assessment should have been conducted within 2 days of referral or the SOC date ordered by the physician for patient #3. On 12/04/25 at 10:53 a.m. to 11:39 a.m., Staff B stated the initial evaluation/SOC comprehensive assessment should have been conducted within 2 days of referral or the SOC date ordered by the physician for patients #4, 5 and #8.”

“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 individualized patient POC included physician reporting parameters for monitoring the patient’s weight were a part of the POC for one (Patient #4) of 13 patients. Findings: Patient #4 A review of the POC dated 10/12/25 to 12/10/25 showed orders for SN to monitor the patient’s weight each visit and report to the physician weight gain or loss. The POC showed no physician reporting parameters for monitoring the patient’s weight and showed no goals for weight management interventions, showed no physician notification and no changes in orders. On 12/04/25 at 10:53 a.m., Staff A stated the POC did not include physician reporting parameters and no goals for weight monitoring.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were a part of the patients’ POCs for SN to report patient’s weight gain or loss of 5 pounds to the physician after a changed reporting parameter of 169 to 189 pounds for one (Patient #1) of 13 patients. Findings: Patient #1 A review of the POC dated 10/14/25 to 12/12/25 showed orders for SN to monitor the patient’s weight each visit and report weight loss or gain of 5 pounds and weight of less than 192 pounds or greater than 202 pounds. The clinical record showed an order dated 11/20/25 changing the reporting parameter to less than 169 to greater than 189 pounds but did not change SN to report weight loss or gain of 5 pounds. SN visit note dated 12/02/25 showed the patient’s weight had increased to 180.6 pounds (6.6-pound increase) the visit note showed no physician notification and no change in orders. On 12/04/25 at 10:30 a.m., Staff A stated the SN should have removed the order to report weight loss or gain of 5 pounds when the reporting parameter was changed.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 (Patients #4 and #6) of 13 patients. Findings: Patient #4 A review of a POC dated 10/12/25 to 12/10/25 showed orders for OT to evaluate with a frequency of one time a week for one week. The clinical record showed no OT evaluation, no patient refusal, no physician notification or changes in the order. A review of a physician’s order dated 11/11/25 showed the OT evaluation was discontinued. On 12/04/25 at 10:53 a.m., Staff A stated the patient refused the OT evaluation. On 12/04/25 at 10:55 a.m., Staff B stated the agency did not notify the physician the patient had refused the OT evaluation when the evaluation was due. Patient #6 A review of a POC dated 09/22/25 to 11/20/25 showed orders for SN to assess, perform and instruct wound site care to the right hip stage II pressure ulcer: cleanse site with normal saline, apply Silvex wound gel and cover with a dry dressing every visit with a SN frequency of one time a week for nine weeks. SN visit notes dated 10/01/25, 10/10/25, 10/22/25 and on 11/05/25 showed the wound care was performed by the patient’s caregiver, showed no physician notification and no changes in orders. On 12/04/25 at 11:16 a.m., Staff B stated the SN did not communicate with the physician that the patient’s caregiver was performing wound care until 11/07/25.”

“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 agency failed to ensure: 1. SN reported systolic blood pressure findings outside of the physician ordered reporting parameters for one (Patient #2) of 13 patients. 2. SN conducted weight monitoring assessment as ordered for one (Patient #4) of 13 patients. 3. SN conducted wound site care as ordered for one (Patient #6) of 13 patients. 4. SN reported pain assessment findings outside of the physician ordered reporting parameters for two (Patients #7 and #9) of 13 patients. 5. SN conducted SN visits as ordered for one (Patient #7) of 13 patients. Findings: Patient #2 A review of the POC dated 11/04/25 to 01/02/26 showed orders for SN to monitor the patient’s blood pressure each visit and report to the physician systolic blood pressure greater than 160. SN visit notes dated: · 11/18/25 showed a systolic blood pressure of 173 · 11/28/25 showed a systolic blood pressure of 171 The SN visit notes showed no physician notifications and no changes in orders. On 12/04/25 at 10:34 a.m., Staff A stated the SN did not report the systolic blood pressures during the 11/08/25 and 11/28/25 visits. Patient #4 A review of the POC dated 10/12/25 to 12/10/25 showed orders for SN to monitor the patient’s weight each visit. SN visit note dated 11/08/25 showed no weight assessment was conducted and showed no patient refusal of care, no physician notification and no changes in orders. On 12/04/25 at 10:53 a.m., Staff A stated the SN did not assess the patient’s weight during the 11/08/25 visit. Patient #6 A review of a POC dated 09/22/25 to 11/20/25 showed orders for SN to assess, perform and instruct wound site care to the right hip stage II pressure ulcer: cleanse site with normal saline, apply Silvex wound gel and cover with a dry dressing every visit with a SN frequency of one time a week for nine weeks. SN visit notes dated 10/27/25 and on 10/31/25 showed no wound care was performed, no physician notification and no changes in orders. On 12/04/25 at 11:16 a.m., Staff B stated the SN did not perform wound site care during the 10/27/25 and 10/31/25 visits. Patient #7 A review of the POC dated 10/06/25 to 12/04/25 showed orders for SN to monitor the patient’s pain each visit and report to the physician pain levels greater than 4 of 10 with a SN frequency of one time a week for nine weeks. SN visit notes dated: · 10/09/25 showed a pain level of 7 · 10/30/25 showed a pain level of 5 · 11/02/25 showed a pain level of 8 The SN visit notes showed no physician notifications and no changes in orders. A review of the clinical record showed no SN visit was conducted during the week of 11/23/25 to 11/29/25 (one visit ordered, no visit conducted) and showed no missed visit note, physician notification and no change in orders. On 12/04/25 at 11:32 a.m., Staff B stated: 1. The SN did not report the patient’s pain level that was greater than 4 of 10 during the SN visits on 10/09/25, 10/30/25 and 11/02/25. 2. The SN did not conduct a visit during the week of 11/23/25 to 11/29/25. Patient #9 A review of the POC dated 10/03/25 to 12/01/25 showed orders for SN to monitor the patient’s pain each visit and report to the physician pain levels greater than 5 of 10 with a SN frequency of one time a week for nine weeks. SN visit notes dated: · 10/21/25 showed a pain level of 6 · 11/07/25 showed a pain level of 6 · 11/21/25 showed a pain level of 6 · 11/28/25 showed a pain level of 6 The SN visit notes showed no physician notifications and no changes in orders. On 12/04/25 at 11:44 a.m., Staff B stated the SN did not report the patient’s pain level that was greater than 5 of 10 during the SN visits on 10/21/25, 11/07/25, 11/21/25 and 11/28/25.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure OT visit notes were completed after the visits for one (Patient #9) of 13 patients. Findings: Patient #9 A review of the POC dated 10/03/25 to 12/01/25 showed orders for OT visit frequency of one time a week for six weeks. OT visits plotted for 11/05/25 and 11/12/25 showed no OT visits were conducted, missed or refused. On 12/04/25 at 11:44 a.m., Staff B stated the therapy visits are not scheduled in the eMR until the visit notes are received and processed into the system. On 12/04/25 at 2:00 p.m., Staff C stated the OT visits notes for 11/05/25 and 11/12/25 had not been submitted from the therapy company and were not available for review.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit notes showed documentation of interventions conducted and patient responses for two (Patients # 2 and #5) of 13 patients. Findings: Patient #2 A review of the POC dated 11/04/25 to 01/02/26 showed orders for SN to assess and perform wound care interventions to left buttock and the sacrum wound sites each visit. SN visit notes dated: · 11/05/24 showed no wound site interventions or patient response to treatment during the visit. · 11/07/24 showed no wound site interventions or patient response to treatment during the visit. · 11/11/24 showed no wound site interventions or patient response to treatment during the visit. · 11/14/24 showed no wound site interventions or patient response to treatment during the visit. · 11/18/24 showed no wound site interventions or patient response to treatment during the visit. · 11/25/24 showed no wound site interventions or patient response to treatment during the visit. · 11/28/24 showed no wound site interventions or patient response to treatment during the visit. The SN visit notes showed no physician notifications and no changes in orders. On 12/04/25 at 10:34 a.m., Staff A stated SN clinical visit notes did not document wound site interventions.”