Mays Housecall Home Health of Tulsa, LLC

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.

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.

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.

The agency failed to ensure care was coordinated between the agency and physician for two (Patients #4 and #6) of 13 patients.

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.

The agency failed to ensure OT visit notes were completed after the visits for one (Patient #9) of 13 patients.

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.

Agency staff failed to provide services according to physician orders for two (#3 and #6) of ten (#1- #10) records reviewed.

The PT failed to conduct the initial assessment within 48 hours of the referral as required for one (#6) of ten (#1 - #10) records reviewed.

SN staff failed to review all medications the patient was currently using as part of the comprehensive assessment in order to identify possible side effects and drug interactions for one (#6) of ten (#1 - #10) records reviewed.

The agency failed to ensure the RN conducted Supervisory Aide Visits at least every 14 days for three (#1, #5 and #7) of four (#1, #3, #5 and #7) records reviewed with orders for Home Health Aide (HHA) services.