Mays Housecall Home Health of Durant

“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 and/or SOC comprehensive assessment was conducted within 48 hours of referral for two (Patients #1 and #10) of 17 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 12/12/24 and the initial evaluation/SOC assessment occurred on 12/20/24 (8 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 12/17/25 at 1:53 p.m., Staff A stated the initial evaluation/SOC comprehensive assessment was not conducted within 2 days of referral or the SOC date ordered by the physician. Patient #10 A review of the clinical record showed the agency received referral information on 06/20/25 and the initial evaluation/SOC assessment occurred on 06/23/25 (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. On 12/17/25 at 3:14 p.m., Staff A stated the initial evaluation/SOC comprehensive assessment was not conducted within 2 days of referral or the SOC date ordered by the physician.”

“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 ankle circumference were a part of the POC for one (Patient #6) of 17 patients. Findings: Patient #6 A review of the POC dated 10/19/25 to 12/17/25 showed orders for SN to monitor the patient’s weight or ankle circumference measurement each visit and report to the physician weight gain or loss and/or increase in ankle circumference. The POC showed no physician reporting parameters for monitoring the patient’s ankle circumference measurement, no physician notification and no changes in orders. On 12/17/25 at 2:31 p.m., Staff A stated the POC did not include physician reporting parameters for ankle circumference measurements.”

“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 conduct weight monitoring assessments every visit and report weight gain or loss outside of reporting parameters for three (Patient #3, 6 and #12) of 17 patients. 2. PT conduct PT visits as ordered for two (Patients #4 and #15) of 17 patients. 3. SN report blood pressure and heart rate assessment findings outside of the physician ordered reporting parameters for three (Patients #5, 6 and #8) of 17 patients. 4. SN report pain assessment findings outside of the physician ordered reporting parameters for one (Patient #6) of 17 patients. 5. SN conduct SN visits as ordered for two (Patients #9 and #10) of 17 patients. 6. SN conduct resumption of care assessment as ordered for one (Patient #13) of 17 patients. Findings: Patient #3 A review of the POC dated 10/29/25 to 12/27/25 showed orders for SN to monitor the patient’s weight each visit and report to the physician a weight less than 160 pounds. A SN visit note dated 11/05/25 showed a weight of 156.6 pounds the SN visit note showed no physician notifications and no changes in orders. On 12/17/25 at 2:12 p.m., Staff A stated: 1. The SN did not report the patient’s weight to the physician at the time of the visit. 2. A fax to notify the physician was sent to the physician’s office on 11/07/25. At 3:34 p.m., Staff B stated the physician should have had a fax notification of assessment findings outside of the reporting parameters on the POC within 24 hours of the visit. Patient #4 A review of the POC dated 11/05/25 to 01/03/25 showed orders for PT frequency of two times a week for three weeks effective 11/09/25. A review of the clinical record showed no PT visit was conducted: 1. During the week of 11/09/25 to 11/15/25 (two visits ordered, no visit conducted) and showed no missed visit note, physician notification and no change in orders. 2. During the week of 11/16/25 to 11/22/25 (two visits ordered, no visit conducted) and showed no missed visit note, physician notification and no change in orders. On 12/17/25 at 2:21 p.m., Staff A stated the PT did not conduct visits as ordered on the POC. Patient #5 A review of the POC dated 10/30/25 to 12/28/25 showed orders for SN to monitor the patient’s blood pressure and heart rate each visit and report to the physician a systolic blood pressure greater than 150 and heart rate less than 60 bpm. A review of SN visits notes showed the following: · A SN visit note dated 11/25/25 showed a systolic blood pressure of 168 and showed no physician notifications and no changes in orders. · A SN visit note dated 12/16/25 showed a heart rate of 52 bpm and showed no physician notifications and no changes in orders. On 12/17/25 at 2:24 p.m., Staff A stated: 1. The SN did not report the patient’s assessment findings outside of the physician reporting parameters at the time of the SN visits. 2. Faxes to notify the physician for the assessment findings outside of the reporting parameters on 11/25/25 and 12/16/25 were sent to the physician’s office through the online portal, we do not know what dates the notifications occurred. 3. No other fax notifications were sent for the assessment findings on 11/25/25 and 12/16/25. At 3:34 p.m., Staff B stated the physician should have had a fax notification of assessment findings outside of the reporting parameters on the POC within 24 hours of the visit. Patient #6 A review of the POC dated 10/19/25 to 12/17/25 showed orders for SN to monitor the patient’s blood pressure, heart rate, weight and pain level each visit and report to the physician a weight less than 120 pounds, diastolic blood pressure less than 60, heart rate greater than 80 bpm and pain level greater than 5 of 10. A review of SN visits notes showed the following: · A SN visit note dated 10/19/25 showed a diastolic blood pressure of 58 and a heart rate of 93 bpm weight and showed no physician notifications and no changes in orders. · A SN visit note dated 10/28/25 showed a reported pain level of 8 of 10 and showed no physician notifications and no changes in orders. · A SN visit note dated 11/04/25 showed a reported pain level of 8 of 10 and showed no physician notifications and no changes in orders. · A SN visit note dated 12/03/25 showed a weight of 110 pounds and showed no physician notifications and no changes in orders. On 12/17/25 at 2:31 p.m., Staff A stated: 1. The SN did not report the patient’s assessment findings outside of the physician reporting parameters at the time of the SN visits. 2. A fax to notify the physician for the assessment findings outside of the reporting parameters on 10/19/25 was sent to the physician’s office on 10/21/25. 3. No other fax notifications were sent for the assessment finding on 10/28/25, 11/04/25 and 12/03/25. At 3:34 p.m., Staff B stated the physician should have had a fax notification of assessment findings outside of the reporting parameters on the POC within 24 hours of the visit. Patient #8 A review of the POC dated 11/12/25 to 01/10/26 showed orders for SN to monitor the patient’s blood pressure and heart rate each visit and report to the physician a systolic blood pressure greater than 150 and heart rate less than 50 bpm. A review of SN visits notes showed the following: · A SN visit note dated 11/13/25 showed a heart rate of 39 bpm and showed no physician notifications and no changes in orders. · A SN visit note dated 12/01/25 showed a systolic blood pressure of 154 and showed no physician notifications and no changes in orders. On 12/17/25 at 2:55 p.m., Staff A stated: 1. The SN did not report the patient’s assessment findings outside of the physician reporting parameters at the time of the SN visits. 2. A fax to notify the physician of the assessment findings outside of the reporting parameters on 12/01/25 was sent to the physician’s office on 12/04/25. 3. No fax notification was sent for the assessment finding on 11/13/25. Patient #9 A review of the POC dated 10/14/25 to 12/12/25 showed orders for SN frequency of four times a week for one week, two times a week for one week then, one time a week for seven weeks. A review of the clinical record showed a SN visit was scheduled on 12/04/25 (one visit ordered) and showed no visit conducted, no missed visit note, no physician notification and no change in orders. On 12/17/25 at 3:10 p.m., Staff A stated the SN did not conduct a visit on 12/04/25 as ordered on the POC. Patient #10 A review of the POC dated 10/21/25 to 12/19/25 showed orders for SN frequency of two times a week for nine weeks. A review of the clinical record showed a SN visit was conducted on 11/25/25 (two visits ordered, one visit conducted) and showed no missed visit note, no physician notification and no change in orders. On 12/17/25 at 3:14 p.m., Staff A stated the SN did not conduct visits as ordered on the POC. Patient #12 A review of the POC dated 10/26/25 to 12/24/25 showed orders for SN to monitor the patient’s weight each visit and report to the physician a weight greater than 268 pounds. A review of SN visits notes showed the following: · A SN visit note dated 11/24/25 showed a weight of 276 pounds and the SN visit note showed no physician notifications and no changes in orders. · A SN visit note dated 12/08/25 showed a weight of 282 pounds and the SN visit note showed no physician notifications and no changes in orders. On 12/17/25 at 3:34 p.m., Staff A stated: 1. The SN did not report the patient’s weight to the physician at the time of the visits. 2. A fax to notify the physician for the assessment findings outside of the reporting parameters on 11/24/25 was sent to the physician’s office on 11/26/25. 3. A fax to notify the physician for the assessment findings outside of the reporting parameters on 12/08/25 was sent to the physician’s office on 12/15/25. At 3:34 p.m., Staff B stated the physician should have had a fax notification of assessment findings outside of the reporting parameters on the POC within 24 hours of the visit. Patient #13 A review of the POC dated 10/11/25 to 12/09/25 showed orders for SN to conduct post in-patient facility stay resumption of care assessment on 10/25/25. A review of the clinical record showed a communication note dated 10/26/25 stated the nurse requested ROC assessment be scheduled for 10/26/25. The clinical record showed no patient refusal of the ROC assessment on 10/25/25, no physician notification and no change in orders. On 12/17/25 at 3:40 p.m., Staff A stated the SN did not conduct the ROC visit as ordered in the POC. Patient #15 A review of the POC dated 10/03/25 to 11/19/25 showed orders for PT frequency of one time a week for six weeks effective 10/05/25. A review of the clinical record showed no PT visit was conducted during the week of 10/05/25 to 10/11/25 (one visit ordered, no visit conducted) and showed no missed visit note, physician notification and no change in orders. On 12/17/25 at 3:49 p.m., Staff A stated the PT did not conduct visits as ordered on the POC.”

“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 clinical visit notes were completed within 24 hours of the visit for two (Patients #7 and #9) of 17 patients. Findings: Patient #7 A review of the POC dated 11/18/25 to 01/16/25 showed a SN visit frequency of one time a week for nine weeks. A review of the clinical record showed a SN visit was conducted on 11/24/25 and the SN visit note was completed on 11/28/25 (four days later). On 12/17/25 at 2:45 p.m., Staff A stated the SN visit note was not completed within 24 hours of the visit. Patient #9 A review of the POC dated 10/14/25 to 12/12/25 showed a SN visit frequency of one time a week for nine weeks. A review of the clinical record showed: · SN visit was conducted on 11/02/25 and the SN visit note was completed on 11/05/25 (three days later). · SN visit was conducted on 11/23/25 and the SN visit note was completed on 11/26/25 (three days later). On 12/17/25 at 3:10 p.m., Staff A stated the SN visit notes were not completed within 24 hours of the visit.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of an administrator and alternate administrator designee for the agency affecting 353 patients and all employees. Findings: A review of governing body meeting minutes dated 01/23/25 and 04/24/25 showed no appointment of the administrator or alternate administrator designee for the agency. Additional governing body administrative records for 2025 were requested, yielding no results. On 12/17/24 at 3:00 p.m., Staff B stated the governing body meeting minutes showed no appointment of the administrator or alternate administrator designee for the agency.”

“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 # 1 and #7) of 17 patients. Findings: Patient #1 A review of the POC dated 10/16/25 to 12/14/25 showed orders for SN to administer vitamin B12 1000mcg subcutaneous injection every month. A review of SN visit notes dated: · 10/21/25 showed no patient response to medication administration intervention during the visit. · 12/02/25 showed no patient response to medication administration intervention during the visit. · The SN visit notes showed no physician notifications and no changes in orders. On 12/17/25 at 1:53 p.m., Staff A stated the SN visit notes did not document the patient’s response to the medication injections. Patient #7 A review of the POC dated 11/18/25 to 01/16/26 showed orders for SN to assess and monitor the patient’s blood sugar log and perform wound care to the left foot every week: cleanse with Puracin, apply calcium alginate, cover with ABD and stockinet dressing every Monday. A review of SN visit notes dated: · 11/18/25 showed no blood sugar log monitoring and showed no patient response to wound care intervention. · 11/24/25 showed no blood sugar log monitoring and showed no patient response to wound care intervention. · 12/01/25 showed no patient response to wound care intervention. · The SN visit notes showed no physician notifications and no changes in orders. On 12/17/25 at 2:45 p.m., Staff A stated the SN visit notes did not document the patient’s blood sugar log monitoring and showed no patient response to the wound care interventions.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer and/or discharge summary was provided to the receiving service provider for (Patients #8, 14, 15 and #17) of 17 patients. Findings: Patient #8 A review of the clinical record showed transfer from the agency on 11/14/25 to inpatient hospital services showed no transfer summary was provided to the inpatient hospital service provider and a copy of the transfer summary was sent to the physician on 11/24/25 (10 days later). On 12/17/25 at 2:55 p.m., Staff A stated: 1. The transfer summary was not provided to the receiving in-patient service provider. 2. The physician did not receive a copy of the transfer summary within 2 business days. Patient #14 A review of the clinical record showed transfer from the agency on 11/14/25 to inpatient hospital services showed no transfer summary was provided to the inpatient hospital service provider and no transfer summary was sent to the physician. On 12/17/25 at 3:46 p.m., Staff A stated: 1. The transfer summary was not provided to the receiving in-patient service provider. 2. The physician did not receive a copy of the transfer summary. Patient #15 A review of the clinical record showed discharge from the agency on 11/18/25 to hospice services showed no discharge summary was provided to the hospice service provider and no discharge summary was sent to the physician. On 12/17/25 at 3:49 p.m., Staff A stated: 1. The discharge summary was not provided to the hospice service provider. 2. The physician did not receive a copy of the discharge summary. Patient #17 A review of the clinical record showed transfer from the agency on 07/29/25 to inpatient hospital services and showed no transfer summary was provided to the inpatient hospital service provider and no transfer summary was sent to the physician. On 12/17/25 at 4:06 p.m., Staff A stated: 1. The transfer summary was not provided to the receiving in-patient service provider. 2. The physician did not receive a copy of the transfer summary.”