Care Option Health Services Inc.
SETH, Jay AA0000159
OASIS-Start of Care D1
04/05/2022 - 05/04/2022
PATIENT DETAILS
SETH, Jay
567 Kirkwood Avenue
Houston, TX 47556
Phone: (872) 457-5767
DOB: 06/14/1938
MBI: 1EG4-TE5-MK73
MO140 - Race/Ethnicity: White
Status: Married
Medicaid #: 6465462122
Gender: Male
HIC: NA
M0150 - Current Payment Source 1 - Medicare (traditional fee-for-service)
Payer: Medicare J11
| Emergency Preparedness | ||
| Triage Class: | Class IV - Low Risk Patients with maximum in home support that can be mobilized with minimal to no assistance should a natural disaster occur. Patient services may be postponed or interrupted 72 hours or more, without adverse effect to the patient. | |
| Disaster Code: | Code 3 - Patient is able to evacuate self | |
| PHYSICIAN RELATED DETAILS | ||
| EROMOSELE, Joseph MD | NPI:1104855493 | Ordering/Referring |
| 8305 N La Homma Blvd Ste B | ||
| Mission, TX 78574 | ||
| Phone: (956) 581-0401 | Fax: (956) 581-0654 | Email: iamnabil63@gmail.com |
| CLINICAL RECORDS | ||
| Episode Timing and Referral | ||
| M0100-Reason for Assessment | 01-Start of Care | |
| M0080 - Discipline of Person Completing Assessment: | JOKODOLA, Dele, RN | |
| M0102- Date of Physician-ordered Start of Care (Resumption of Care): | NA | |
| M0110 Episode Timing: | UK – Unknown | |
| M0104- Date of Referral: | 04/05/2022 | |
| M0030 – SOC Date: | 04/05/2022 10:15 am to 12:13 pm | |
| M0090 – Assessment Completion Date: | 04/07/2022 | |
| PATIENT HISTORY & DIAGNOSES | |||
| Immunization Record: | |||
| Covid-19 Vaccine – Yes | Type: Moderna | ||
| 1st Dose: 04/13/2021 | 2nd Dose: 07/11/2021 | 3rd Dose: 01/05/2022 | 4th Dose: 01/05/2022 |
| Shingles Vaccine – Yes | Type: Shyleterr | Date: 05/18/2020 | |
| Flu Vaccine – Yes | Type: Shyleterr | Date: 05/18/2020 | |
| Pneumonia Vaccine – Yes | Type: Shyleterr | Date: 05/18/2020 | |
| Tetanus Vaccine – Yes | Type: Shyleterr | Date: 05/18/2020 | |
| Tuberculosis Vaccine – Yes | Type: Shyleterr | Date: 05/18/2020 | |
| H1N1 Vaccine – Yes | Type: Shyleterr | Date: 05/18/2020 | |
| Hepatitis Vaccine – Yes | Type: Shyleterr | Date: 05/18/2020 | |
| ALLERGIES: No Known Allergies | |||
| Covid 19 Screening: Yes | ||
| Questionnaire | Care Provider | Patient |
| Temperature | 96.5 oF | 99.4 oF |
| Was PPE Used? | Yes | Yes |
| Traveled internationally within the last 14 days? | No | No |
| Do you have any of the following signs or symptoms of a respiratory infection, such as Shortness of Breath, Sore throat, Fever, Chills, Fatigue, Muscle or Body ache, Headache, Lost of taste or smell, Congestion, Runny nose, Nausea, Vomiting, Diarrhea? | No | No |
| Contact with someone who has respiratory illness or under investigation for COVID-19? | No | No |
| Live in a community where community-based spread of COVID-19 is occurring? | Yes | Yes |
| Contact with anyone who has traveled to countries with sustained-community transmission? | No | No |
| Have you visited someone with confirmed COVID-19? | No | No |
| Have you had a positive COVID-19 Test in the Last 14-days? | No | No |
| (M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? |
| 2 - Skilled Nursing Facility (SNF/TCU) |
| (M1005) Inpatient Discharge Date (most recent): Unknown |
| (M1021) Primary Diagnosis & (M1023) Other Diagnosis | ||||
| Code | Description | E/O | Severity | Date |
| J00.052 | Acute nasopharyngitis [common cold] | O | 01 | 04/08/2022 |
| L50.2 | Urticaria due to cold and heat | O | 02 | 04/08/2022 |
| J00.052 | Acute nasopharyngitis [common cold] | O | 01 | 04/08/2022 |
| L50.2 | Urticaria due to cold and heat | O | 02 | 04/08/2022 |
| (M1028) Active Diagnoses - Comorbidities and Co-existing Condition | 3 - None of the above | |
| (M1030) Therapies the patient receives at home: | 2 - Parenteral nutrition (TPN or lipids) | |
| (M1033) Risk for Hospitalization: | 10 - None of the above | |
| (M1060) A - Height:78 inches | B - Weight: 225 lbs. | |
| LIVING ARRANGEMENTS & SUPPORTIVE ASSISTACE | ||||||
| (M1100) Patient Living Situation | ||||||
| 08- Patient lives with other person(s) in the home, regular nighttime and assistance is available | ||||||
| Does Patient have a Caregiver that is willing and able to assist? | Yes | |||||
| Name | Phone | Age (Yrs) | Sex | Relationship | Availability | |
| BAKESFIELD, Adamu | (281) 232-5613 | 25 | Female | Family friend | Afternoons | |
| (M2102) Types and Sources of Assistance: Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to provide assistance for the following activities, if assistance is needed Excludes all care by your agency staff. |
| 1 - Non-agency caregiver(s) currently provide assistance |
| Patient is receiving Supportive Assistance from | |||
| Name | Phone | Type | Hrs/Week |
| Meals on wheels | (281) 232-5239 | Inadequate cooking. | 2 |
| Medical Social Worker (MSW) referral is Needed? | No |
| Is this patient Homebound? | Yes |
| Homebound Reason: | Tasking Effort to Leave Home |
| Safety Measures: | Slow Position Change |
| Functional Limitations: | Moving slowly |
| Hazards Identified: | |
| Electrical outlets are a potential fire hazard due to the presence of Oxygen tank in the home. | |
| SENSORY STATUS |
| (M1200) Vision (with corrective lenses if the patient usually wears them): |
| 00 - Normal vision: sees adequately in most situations; can see medication labels, newsprint. |
| (M1242) Frequency of Pain Interfering with patient's activity or movement: |
| 00 - Patient has no pain |
| Pain Assessment | ||
| Location: Right Shoulder | Type: Aching Level: 3/10 | Frequency: Intermittent |
| Relived by: Tylenol and Heat | Pertinent Factor: | Pain Status: Unhealed |
| Pain Comment: | ||
| EYES, EARS, NOSE, MOUTH & THROAT | ||||||
| Eyes | WNL: No |
Contacts: Both |
Blind: Right |
Prothesis: Right |
Glaucoma, Surgery | |
| Ears | WNL: No |
Hard of hearing : Left |
Hearing Aid Left |
Deaf: Right |
Tinnitus: Left |
Vertigo |
| Nose: | WNL: No |
Congestion, Loss of smell | ||||
| Neck/Throat | WNL: No |
Hoarseness, Swelling, Difficulty swallowing | ||||
| Mouth | WNL: No |
Gingivitis, Toothache | ||||
| RESPIRATORY STATUS | ||
| (M1400) When is the patient dyspneic or noticeably Short of Breath? | ||
| 00 - Patient is not short of breath | ||
| Is Patient SOB: | Yes, describe what causes SOB | |
| Respiratory Assessment: | ||
| Chest Pain: Yes, Angina | Description: Describe Pain, Frequency, Duration | |
| Relieved by: Yoga possess and taking my medication | ||
| Right Lung Sound: Yes, Wheezing | Left Lung Sound: Yes, Bronchi | |
| Cough: Yes, If Productive, describe sputum color, amount and frequency | ||
| O2 Saturation: Yes, If Productive, describe sputum color, amount and frequency | ||
| Cardiopulmonary: | ||
| Heart Sounds: Irregular | Peripheral Pulse: Faint | Color of Nail Bed: Normal for Race |
| Edema Pedal Rt: Yes | Type of Pitting: +3 | Capillary Refill: Less than 3s |
| Edema Pedal Lt: Yes | Type of Pitting: +3 | Capillary Refill: Greater than 3s |
| Medical Device? | Yes, Loop Recorder, Battery change date: 03/12/2019 | |
| Respiratory Status Goals & Intervention | |
| Goals | |
| Caregiver - will demonstrate improved understanding of energy conservation as evidenced by decreased reports of SOB during episode | |
| Interventions | |
| Caregiver - require instruction on energy conservation for patient's declining functional status and frequent complaints of shortness of breath | |
| Pain Assessment | ||
| Location: Right Shoulder | Type: Aching Level : 3/10 | Frequency: Intermittent |
| Relieved By: Tylenol and Heat | Pertinent Factor: | Pain Status: Unhealed |
| Pain Comment: | ||
| Braden Scale | ||
| SN | Description | Selection |
| 1 | Sensory Perception: Ability to respond meaningfully to pressure-related discomfort | 4. No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. |
| 2 | Moisture: Degree to which skin is exposed to moisture | 4. Rarely Moist: Skin is usually dry; linen requires changing only at routine intervals. |
| 3 | Activity: Degree of physical activity | 3 Walks Occasionally: Walks occasionally during day but for very short distances, with or without assistance. Spends majority of day in bed or chair. |
| 4 | Mobility: Ability to change and control body position. | 4. No Limitations: Makes major and frequent changes in position without assistance. |
| 5 | Nutrition: Usual food intake pattern | 3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered, OR is on a tube feeding or TPN regimen, which probably meets most of nutritional needs. |
| 6 | Friction and Shear | 3. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. |
| Score: 21 No risk of Pressure Ulcer | ||
| Fall Risk Assessment | ||
| SN | Description | Selection |
| 1 | Age | 80 Years Old |
| 2 | Fall History No falls in past year | Fall History No falls in past year |
| 3 | Mobility/Activity and Balance | Ambulate safely without DME or human assistance steady gait, no vertigo |
| 4 | Mental State | Oriented to person, place, and time |
| 5 | Sensory | Normal hearing and vision for age feeding or TPN regimen, which probably meets most of nutritional needs. |
| 6 | Medications | Antidepressants, Antihypertensives, Antiparkinsonians, Diuretics, Vasodilators, Vestibular Depressants Take 1 or 2 listed Medications |
| 7 | Continence | Continent of Bowel or Bladder at all times |
| Score: 4: Medium Fall Risk | ||
| Wound Assessment | |||||||||
| Type | Bruise | ||||||||
| Location | Right Shoulder | ||||||||
| Size (cm) | Length | 5 | |||||||
| Width | 2.5 | ||||||||
| Depth | 0.55 | ||||||||
| Tunneling
Undermining |
1.25 | ||||||||
| Stage, if Pressure Ulcer | 2 | ||||||||
| Surrounding Skin | Warm | ||||||||
| Edema | +2 | ||||||||
| Odor | Foul | ||||||||
| Stoma | None | ||||||||
| Wound Bed | Tissue | Stenosis | |||||||
| Color | Pink | ||||||||
| Drainage | Type | Bloody | |||||||
| Amount | Scant | ||||||||
| Color | Black | ||||||||
| Consistency | Thin mucus | ||||||||
| Wound Care | Cleansed With | Gauze | |||||||
| Blotted With | Gauze | ||||||||
| Covered With | Gauze | ||||||||
| Secured With | Gauze | ||||||||
| Wound Status | Gauze | ||||||||
| Wound Stage | Healing | ||||||||
| Comment | |||||||||
| NUTRITIONAL RISK SCREENING | Score |
| Unintentional Weight Loss greater than 10 lbs. in last 3 months | 3 |
| Chewing and or Swallowing Problems | 3 |
| Inadequate or Poorly Balanced Diet | 3 |
| Slow Healing Wound | 3 |
| Hyperemesis Gravidarum | 6 |
| Tube Feeding / TPN | 6 |
| Cachexia | 6 |
| Diabetes Mellitus | 6 |
| Modified Diet | 4 |
| Difficulty Managing Diet | 4 |
| Score = 18 Patient may require referral to registered dietician | |
| Was Patient Referred to Dietician? | Yes |
| Nutritional Requirements | Full Liquid Diet, Clear Liquid Diet, Regular Diet | ||||||||
| Access Device: | Yes | ||||||||
| Nutritional Tube Feeding: ENTERAL / PARENTERAL FEEDING | |||||||||
| Access Device | Pump Type | Feeding Rate | Flush Amount | Performed by | |||||
| Nasogastric | Continuous | 15 ML/Hr. | 18 ML/Hr. | Nurse | |||||
| Feeding Intervention | |||||||||
| Site dressing, monitored the patient for feeding tolerance | |||||||||
| Mental Status | |
| Oriented to Place, Oriented to Time, Oriented to Person | |
| Comment: | |
| Neurological | ||
| Mental State | Mental Status | Other |
| Alert/Oriented | Oriented to place, Time and Person | Forgetful |
| Grasp: | Pupils | Eye |
| RH: Unequal LH: Unequal | PERRLA: Yes | Both |
| Impairment | ||
| Vision: Cataract, Glaucoma | Speech: Nonverbal | Hearing: Deaf |
| Impairment | ||
GG0100 - Score Guide
- Dependent - A helper completed the activities for the patient
- . Needed Some Help - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.
- Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.
- Unknown
- . Not Applicable
GG0100. Prior Functioning: Everyday Activities: Indicate the patient’s usual ability with everyday activities prior to the current illness, exacerbation, or injury.
| A. Self Care: Code the patient’s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury | 3 |
| B. Indoor Mobility (Ambulation): Code the patient’s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury | 3 |
| C. Stairs: Code the patient’s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation or injury. | 3 |
| D. Functional Cognition: Code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury | 3 |
GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury.
| Yes | No | NA | |
| A. Manual wheelchair | ¥ | ||
| B. Motorized wheelchair and/or scooter | ¥ | ||
| C. Mechanical lift | ¥ | ||
| D. Walker | ¥ | ||
| E. Orthotics/Prosthetics | ¥ | ||
| Z. None of the above | ¥ |
Coding Guide:
Safety and Quality of Performance - If helper assistance is required because patient’s performance is unsafe or of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations - (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
| 1. SOC/ROC Performance | 2. Discharge | GG0130. Self-Care. Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s). |
| 03 | 02 | A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. |
| 03 | 02 | B. Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth and manage equipment for soaking and rinsing them. |
| 03 | 02 | C. Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. |
| 03 | 02 | E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower |
| 03 | 02 | F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. |
| 03 | 02 | G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. |
| 03 | 02 | H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. |
|
(GG0170) Mobility . Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s). |
1. SOC/ROC Performance | 2. Discharge |
| A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed | 03 | 02 |
| B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. | 03 | 02 |
| C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. | 03 | 02 |
| D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. | 03 | 02 |
| E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). | 03 | 02 |
| F. Toilet Transfer: The ability to get on and off a toilet or commode. | 03 | 02 |
| G. Car Transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt | 03 | 02 |
| I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. | 03 | 02 |
| J. Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns | 03 | 02 |
| K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. | 03 | 02 |
| L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. | 03 | 02 |
| M. 1 step (curb): The ability to go up and down a curb and/or up and down one step | 03 | 02 |
| N. 4 steps: The ability to go up and down four steps with or without a rail | 03 | 02 |
| O. 12 steps: The ability to go up and down 12 steps with or without a rail. | 03 | 02 |
| P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. | 03 | 02 |
| Q. Does patient use wheelchair and/or scooter?
0. No – Skip GG0170R, GG0170RR1, GG0170S and GG0170SS1 1. Yes – Continue to GG0170R, Wheel 50 feet with two turns |
||
| R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns
RR1. Indicate the type of wheelchair or scooter used. 1-Manual 2-Motorized |
05 | 04 |
| S. Wheel 150 Feet: Once seated in wheel/scooter, the ability to wheel atleast 150 feet in a corridor or similar space
RR1. Indicate the type of wheelchair or scooter used. 1-Manual 2-Motorized |
05 | 05 |
| Medication Profile |
|
Maalox Antacid null Liquid Oral (N) 2 Liquid - Oral - every 12 hours CLASS: Drugs for Acid Related Disorders INDICATIONFlatulence, Heartburn, Dyspepsia, Acid Regurgitation, Gastroesophageal Reflux, Anginal Pain caused by Gas, Colic, Duodenal Ulcer, Gastric Ulcer, Bloating, Stomach pains caused by Gastric Acid, Abdominal Pain, Pain, Inflammatory, Gas, Upset stomach, Sour stomach, Acid Reflux, Acid indigestion, Skin Irritation, Hyperphosphatemia |
|
Tylenol 8HR 650MG Tablet Oral (N) 2 Tablet - By Mouth - every 12 hours CLASS: Analgesics INDICATIONFever, Moderate to severe pain, Mild to moderate pain, Severe Pain, Minor aches and pains, Coughing, Nasal Congestion, Allergies, Pain, Cold, Minor pain, Soreness, Muscle, Headache, Menstrual Cramps, Dyskinesia of the Biliary Tract, Dyskinesia of the Urinary Tract, Spasms |
|
Viagra 25MG Tablet Oral (N) 1 Tablet - Oral - As Needed CLASS: Fertility Enhancement INDICATIONPremature Ejaculation, Erectile Dysfunction, Pulmonary Arterial Hypertension (PAH), NYHA Functional Class II-III Pulmonary arterial hypertension |
HHA Care Plan:
| Activity | Type | Frequency | |||||||
| Bath | Yes | Bed bath partial | At Patient Request | ||||||
| Hygiene/Grooming | Yes | Nail care, Oral care, Shampoo | Every Visit | ||||||
| Procedure | Yes | Ostomy care | Every Visit | ||||||
| Activity | Yes | Assist to turn | Every Visit | ||||||
| Nutrition | Yes | Meal preparation | Every Visit | ||||||
| Others | Yes | Laundry, Grocery shopping | Every Visit | ||||||
| Notify RN if: | Bruises, New Wound, Swelling and Decreased Appetite | ||||||||
| Skilled Teaching provided this visit |
| PATIENT IS A 44YR OLD FEMALE. PATIENT ADMITTED TO HOMEHEALTH SERVICES WITH HISTORY OF PARAPLEGIA, ABNORMALITY OF GAIT, NEUROGENIC BLADDER/BOWEL, PT DEPEND ON CG FOR ASSISTANCE FOR ALL ACTIVITIES. ASSESSMENT DONE OF ALL BODY SYSTEM INCLUDING VS. PATIENTS MEDICATION REVIEWED WITH THE CG. WITH FOLEY FR18 WITH DRAIAGE BAG, AND INSTRUCTIONS ON MEASURES TO SAFETY MEASURES, MONITOR BP, S&S TO REPORT TO MD/SN. ALL MEDICATIONS REVIEWED WITH CAREGIVER. PT REQUIRE PT/OT REFERRALLS MADE PER MD ORDERS |
| Name | Signature | Date; Time | |
| Patient/Family/Caregiver | SETH, Jay |
|
04/05/22 12:10 pm |
| Skilled Assessor | JOKODOLA, Dele RN |
|
04/05/22 12:13 pm |