Altruist Home Care Solutions

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview the agency failed to encode and electronically transmit each completed OASIS assessment (a tool used by CMS to collect certain patient information) to the CMS system within 30 days of completing the assessment of the beneficiary for 26 OASIS assessments submitted during 12/01/2023 to 12/31/2024 for 22 patients. Poor care patterns could not be identified by the agency or CMS potentially subjecting patients to poor health outcomes. The surveyor reviewed the agency OASIS errors report in IQUES on 12/31/2024 which documented the agency had submitted 26 comprehensive assessments more than 30 days after the date of the assessment. The report listed 22 patient names as being affected by the late transmission of their comprehensive assessments from 12-10/2023 to 12/31/2024. An interview was conducted on 01/03/2025 at 12:26 PM with the Interim DON. The surveyor asked about the late OASIS assessment transmissions. The Interim DON stated the Alternate Administrator was responsible for uploading the assessments. The DON stated the agency switched to a new electronic medical record system in July 2024 and “records of transmitting and visits disappear.” The DON described the reason for the late OASIS transmission was late documentation by the nurses and the turnover in Director of nurses. The surveyor asked if the OASIS reports were reviewed as part of the agency’s QAPI process. The DON stated they were. The surveyor asked if the lack of timely transmissions could affect the ability of the agency to use the data in the QAPI review to evaluate care trends. The DON stated that it could. An interview was conducted on 01/06/2025 at 4:10 PM with the Administrator. The surveyor asked about the late OASIS assessment transmissions. The Administrator stated she was aware of the late transmissions around the time of the agency’s change in electronic medical record vendor. The Administrator stated it “might have been an issue with the submitter ID being wrong” in the current electronic medical record system and “it was probably a software issue.” The Administrator stated the Alternate Administrator was not available for an interview as she was off due to a death in the family. Agency policy IM.10 Timeliness read in part: Encoding and transmission of OASIS data to CMS is performed at least monthly and prior to billing. The OASIS is required to be transmitted to CMS within 30 days of date the assessment is completed.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record review and interview the encoded OASIS data for 5 (Patient 1,2, 3,4, and 6) of 7 records reviewed was not accurate and consistent with the current status of the patients at the time the OASIS were completed. Patient’s clinical status, care needs, and outcomes could not be evaluated and compared with past performance and against other providers. Record review of Patient #1 revealed a comprehensive assessment signed by the Interim DON dated 09/10/2024. The assessment documented: “Tele visit: Instructed PT/CG this is tele visit and that all assessments and vital signs obtained from PT/CG.” The assessment documented the patient with a history of pressure ulcers (bedsore- injury to skin and underlying tissue resulting from prolonged pressure on the skin) “that are now resolved.” A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The POC for Patient #1 dated 09/12/2024 to 11/10/2024 with a start of care date 09/10/2023 contained diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (in ability to regulate blood sugar that has damaged the nerves), Hypertension (high blood pressure), Chronic Pain syndrome (persistent pain that lasts weeks or years), Hypothyroidism (thyroid doesn’t produce enough thyroid hormone), Bed Confinement Status (patient is unable to tolerate activity outside of the bed), and Long term Use of Insulin (use of insulin over period of time which can negatively affect cardiovascular system). The POC failed to include a wound diagnosis, wound care orders, and wound care supplies. Review of nurses notes by LVN A documented wound care to the patients left buttock open surgical wound on visits dated 09/13/24, 09/16/24, 09/18/24, 09/20/24, 09/23/24, 09/25/24, 09/27/24, and 09/30/24, 10/02/2024, 10/04/2024, 10/07/2024, 10/09/2024, 10/11/2024, 10/14/2024, 10/16/2024, 10/18/2024, 10/21/2024, 10/23/2024, 10/25/2024, 10/28/2024, 10/30/2024, and 11/01/2024. The visit note dated 11/04/2024 was blank. Record review of Patient #1 revealed a comprehensive assessment signed by the Interim DON dated 11/08/2024. The assessment documented: “Tele visit: Instructed PT/CG this is tele visit and that all assessments and vital signs obtained from PT/CG… Wound care not performed” as this was not a scheduled dressing change day. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. On the same date, 11/08/2024 review of the clinical record found a nurses note by LVN A that documented wound care to the patients left buttock open surgical wound during the visit. A home visit by the surveyor was made to Patient #1’s residence on 01/02/25 at noon. The patient stated LVN A came Monday, Wednesday and Friday to change his wound on his left buttocks. The patient stated LVN A had come since the client was discharged from the hospital and provided wound care. The patient stated the RN did not come to the house on 09/11/2024 and 11/08/2024, but talked with him on the telephone. Patient #3 stated he preferred only LVN A come to the house. Record review of Patient #2 revealed a comprehensive assessment signed by the Interim DON dated 11/07/2024. The assessment documented this was a “tele visit” due to staff and patient with flu-like symptoms with vital signs obtained from the patients records and conversation with the patients. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The POC for Patient #2 dated 11/12/2024 to 01/10/2025 with a start of care date 07/15/2024 contained diagnoses: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (inability to regulate blood sugar that has damaged the kidneys), Hypertension (high blood pressure), Ashma (breathing disorder causing wheezing, coughing and shortness of breath), Hypothyroidism (thyroid doesn’t produce enough thyroid hormone), and Hyperparathyroidism (excess of hormone by the parathyroid gland). The POC was missing blood sugar parameters to report to the physician. The surveyor attempted to make a home visit to Patient #2 on 01/02/205 at 1PM. There was no answer to door or telephone. Record review of Patient #3 revealed a comprehensive assessment signed by the Interim DON dated 11/27/2024. The assessment documented failed to document assessment of endocrine and psychosocial status. A further review of the patient’s record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The POC for Patient #3 dated 10/01/2024 to 11/29/2024 with a start of care date 12/06/2023 contained diagnoses: Quadripelgia (partial or total paralysis of the arms, hands, trunk, legs, and pelvic organs), Spastic Quadriplegic Cerebral Palsy (muscle contractions, stiffness and immobility affecting all 4 limbs) Neurogenic bladder (damage of nerves and muscles that control the bladder), Mood Disorder (serious mental illness that affects a person’s mood and behavior), Personal History of urinary tract disorder (infections of the urinary system). The POC failed to include psychosocial status. A home visit by the surveyor was made to Patient #3’s residence on 01/02/25 at 1:40 PM. The patient stated LVN A came once a month to change his urinary catheter. Patient #3 stated a nurse called him 11/27/24 to ask him some health questions. The patient stated the nurse did not come to the house and spoke with him on the telephone. Patient #3 stated he preferred only LVN A come to the house. Record review of Patient #4 revealed a Start of care comprehensive assessment signed by RN A for the start of care date of 03/16/2024. The assessment had many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #4 recertification comprehensive assessment for the certification period 05/15/2024 to 07/13/2024 signed by the Interim DON and dated 05/14/2024 revealed many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The Plan of care dated 05/15/2024 to 07/13/2024 which stated the start of care was 05/15/2024 (not 03/16/2024) contained no diagnoses, Advance directives information, safety measures, mental /cognitive status, psychosocial status, neurological status, prognosis, nutritional requirements, caregiver status, prognosis, activities permitted, DME and supplies, no medications, no frequency and duration for nursing, services, goals, homebound status, potential, and discharge plan. Record review of Patient #4 recertification comprehensive assessment for the certification period 07/11/2024 to 09/11/2024 signed by the Interim DON and dated 07/11/2024 revealed many blank areas including: gastrointestinal and psychosocial status, Durable medical equipment information, and supplies. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Review of Patient #4s plan of care dated 07/14/2024 to 09/11/2024 which stated the start of care was 05/15/2024 contained Diagnoses of Hypertension (high blood pressure), Chronic Kidney Disease (longstanding disease of the kidneys that may lead to kidney failure), Migraine (debilitating headaches), and Dizziness (balance issues). The POC did not contain psychosocial status, Durable medical equipment information, and supplies needed. Record review of Patient #6 revealed a Start of care comprehensive assessment signed by RN C for the start of care date of 06/14/2024. The assessment had mostly blank areas including: Advance directives information, vital signs, vital sign parameters to report to the physician, past medical history, risk assessment, health screening, immunization history, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. The assessment had an attached document that was a printout of only the OASIS (a data collection tool used by Medicare-certified home health agencies to assess and report information on their patients at regular intervals that must be incorporated into an agency’s comprehensive assessment) required items. Patient #6’s comprehensive assessment failed to include wound measurements, or wound assessments. The assessment failed to incorporate all the OASIS data and the agency assessment data. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The Plan of care for Patient #6 dated 06/14/2024 to 08/12/2024 which stated the start of care was 06/14/2024 contained diagnoses of Hypertension (high blood pressure) and Type 2 Diabetes Mellitus (inability to regulate blood sugar.) The plan of care did not contain a diagnosis related to the wound care being provided or wound care orders. On a nurses note dated 06/19/2024 the Interim DON documented that the surgical wound was not healed. An interview was conducted with the Interim DON on 01/03/2025 at 12:26 PM. The surveyor reviewed the findings for Patient #6 and asked about the missing wound assessment. The Interim DON stated the wound assessment documentation was not downloaded from EMR BB, only the OASIS required contents out of the initial assessments. The surveyor reviewed the findings of the record reviews and incomplete comprehensive assessments for each patient. The Interim DON stated she had completed the assessments by telephone “since COVID (a world wide respiratory infection).” The surveyor asked why these visits were not done in person. The Interim DON stated: She did them by telephone “if we have nurses sick or patients that only want LVN A and won’t allow other nurses in the home.” The Interim DON stated she did the assessments by telephone due to patient or nurse illness when the comprehensive assessments were due and they didn’t have another nurse or DON to do them. The Interim DON stated she documented that the visits were by telephone in the patient records for most of the assessments done by telephone. The Interim DON stated she used clinical information from the LVN’s notes to complete the vital signs and other clinical information. The interim DON stated the wound care orders and supplies should be on Patient #1’s assessment and orders and “I just missed it.” The Interim DON stated she lived in Oklahoma and came to the metroplex several times per year. The interim DON stated she came in September 2024, and the last time was a “couple of weeks ago.” The Interim DON stated she did a telephonic comprehensive assessment for Patient #4 and just forgot to document the assessment “was telephonic.” The Interim DON stated most of the assessments were done in person but when they turned over the DON or were short staffed, she did them by telephone. The Interim DON stated the new EMR software AA used for documenting assessments and care “doesn’t work well.” The Interim DON stated the new EMR AA “lost narratives and wound assessments.” The surveyor asked why the assessments prior to July 2024 contained only the OASIS items and not all of the comprehensive assessment items. The Interim DON stated the Alternate Administrator was responsible for downloading records from the previous EMR into the new one, and if she only downloaded the M items (OASIS required items) then the assessments that were downloaded were incomplete. The Interim DON stated she could not access the previous EMR clinical records at this time. The Interim DON stated her position was normally as QAPI and she reviewed the assessments, clinical documentation, and contacted the patients by telephone and spoke with the nurses. The Interim DON stated she was the Interim DON when they turned over DON’s. An interview was conducted on 01/06/2025 at 4:10 PM with the Administrator. The surveyor shared the findings regarding comprehensive assessments being incomplete, inaccurate, and transmitted late. The Administrator stated she was aware of the late transmissions around the time of the agency’s change in electronic medical record vendor. The Administrator stated it “might have been an issue with the submitter ID being wrong” in the current electronic medical record system and “it was probably a software issue.” The Administrator stated the Alternate Administrator was not available for an interview as she was off due to a death in the family. The surveyor asked if the Administrator was aware of the comprehensive assessments by telephone. The Administrator stated she was aware. No additional information was provided to explain or clarify the findings. The surveyor explained the possible condition level deficiencies for comprehensive assessments to the Administrator. The Administrator stated she understood the issues. Agency policy PE.3 Initial Patient Comprehensive Assessment dated 01/01/2017 read in part: Policy – Each patient will receive a patient specific, comprehensive assessment which incorporates OASIS data set for Medicare/Medicaid patients, completed by a Registered Nurse … Each patient will receive a specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes… the assessment data will be collected utilizing the following methods: a. Interaction and interview with the patient/family/physician: b. Assessment using standardized, validated tools; and C. Observation and measurement utilizing the senses and calibrated instruments. 6. The Comprehensive Assessment will include but not be limited to the following: a. Physical assessment/Review of systems; OASIS data set for Medicare/Medicaid patients which would include pertinent diagnoses, prognosis, physical findings, medical history, etc.; AOL’s/Functional status; Medication history, including drug allergies, sensitivities and past adverse drug reactions; Food and environmental allergies; Psycho-social status; Residential environment; Nutritional requirements; Height, weight and BMI per Policy PE.8; and Agencies or companies supplying Outpatient services and/or medical supplies. Screens to identify patients who may require a more in-depth functional assessment by the appropriate discipline, including: Medical history; Problems/needs/strengths of the patient; Education needs of patient/family; Home environment; Any equipment; All medications and past medication compliance history; Patient’s family or support system and the care they are capable of providing and willing to provide; Preventive and periodic health screening; Depression or suicide risk; Pressure ulcer/injury risk; Identifying patients who are at moderate or high nutritional/hydration risk; Abuse; and Safety… • Agency policy PE.4 Patient Reassessment … dated 01/01/2017 read in part: Each patient will be reassessed utilizing the recertification/ follow-Up Comprehensive Assessment during the last five (5) days of the episode (day 56-60)…””

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review the agency failed to ensure the plan of care was followed as ordered by the physician for 3 (Patient 2,4,6) of 7 patients records reviewed. This failure places patients at risk of not receiving adequate services which may lead to negative health outcomes. Record review of Patient #2 for period 11/12/2024-01/10/2025 revealed a plan of care signed by the Interim DON on 11/07/2024 for dates of 11/12/2024 to 01/10/2025. The plan of care ordered weekly skilled nurse visits, PT to evaluate, and stated to notify the physician of vital sign parameters out of range: Pain scale greater than 5 out of 10. A physician order dated 10/24/24 and signed by the Interim DON, contained PT for strengthening, balance and fall prevention. No PT visit notes were present in the patient’s records. Skilled nurse visit notes dated 12/13/2024 and 12/21/2024 and signed by LVN B revealed the patient’s pain was 6 during the assessments. The nurse notes contained a section for documentation of care coordination with the physician and this area was checked marked as N/A (not applicable). Review of the patient’s records failed to find any documentation the physician was notified of the patient’s elevated pain levels as ordered on the POC. Record review of Patient #4 for period 5/15/2024-7/13/2024 revealed a POC for dates of 5/15/2024 to 7/13/2024 signed by the Interim DON. The POC ordered weekly skilled nurse visits for 8 weeks. Patient’s records contained missed nurse visits notes dated 5/22/2024, 5/29/2024,6/08/2024, 6/12/2024, 6/19/2024 and 7/06/2024. The patient’s records contained no documentation of an attempt to reschedule the missed visits and no notification to the physician of the missed visits. Record review of Patient #4 for period 7/14/2024- 9/11/2024 revealed a plan of care signed by the Interim DON for dates 7/14/2024 to 9/11/2024. The plan of care ordered “physical therapy, occupational therapy, will be used for evaluation; establishing/upgrading/teaching home exercise program; patient/family education: teaching on fall safety.” The patient’s records contained no PT or OT visit notes or documentation that an evaluation was done as ordered on the POC. Record review of Patient #6 for period 6/14/2024-8/12/2024 revealed a plan of care signed by the Interim DON for dates 6/14/2024 to 8/12/2024. The plan of care ordered nurse visits twice a week effective 6/16/2024 then weekly effective 6/30/2024. Nurse missed visit notes dated 7/23/2024 and 8/01/2024 contained blank comment sections. Records revealed no documentation of a nurse visit made during the period of 7/17/2024 thru 8/5/2024. The patient’s records contained no documentation of an attempt to reschedule the missed visits and no notification to the physician of the missed visits. An interview was conducted with the Interim DON on 01/03/2025 at 12:26 PM. The surveyor asked about the PT orders on Patient #2s plan of care. The Interim DON stated Patient #2 had an order for a PT evaluation and she could not explain why it was not done. Interim DON confirmed that the authorization for PT was not submitted, and this was an issue. The surveyor asked about the PT and OT order in the POC for period 7/14/2024-9/11/2024 for Patient #4. The Interim DON stated that she saw Patient #4 once and the patient was seen by PT during the previous certification period 5/15/2024-7/13/2024. The Interim DON stated that PT stopped, and she thought patient had reached the maximum authorized PT visits. The Interim DON reported the patient needed a new therapy order and authorization. The Interim DON could not confirm or provide evidence that a request for PT and OT authorization was done for period 7/14/2024-9/11/2024. The surveyor shared the findings of Patient #2’s pain of 6 on 12/13/2024 and 12/21/2024 with no evidence the physician was notified as ordered on the POC. The Interim DON stated that the agency’s procedure was to contact the doctor and completed a communication note when the patient’s pain is out of parameters. The surveyor asked about the missed visits for Patient # 4 and Patient #6. The Interim DON confirmed the patient’s clinical records contained no documentation of an attempt to reschedule visits and no notification to the physician of the missed visits. The Interim DON provided no additional information or documentation to correct the findings. An interview was conducted with LVN B on 1/03/2025 at 1:51 pm. The surveyor shared the findings of Patient #2’s pain of 6 on 12/13/2024 and 12/21/2024. The nurse notes contained a section for documentation of care coordination with the physician and this area was marked as N/A (not applicable). LVN B stated that the physician was aware that the patient had pain, but she could not confirm if the physician was notified on 12/13/2024 and 12/21/2024 for pain greater than 5 as directed in the plan of care. LVN B provided no additional documentation or evidence to correct the findings. An interview was conducted with the Administrator on 01/06/2025 at 4:35pm. The surveyor shared the findings of missed visits (Patient 4,6), no evidence the physician was notified of pain over 5 (Patient 2), and PT/OT evaluations not being completed (Patient 2, 4). The Administrator stated that the agency tried to not miss visits, and the agency’s procedure was to document on a communication note why the visit was missed and document the notification of the doctor. The Administrator reported, the RN who completed the assessment was responsible for following and updating the POC. The Administrator stated the patient assessments and POCs completed by the RN’s go to QA for review and the DON is responsible for the final review. The Administrator stated that the nurses got mad when QA or the DON send documentation back for corrections and the orders and POC’s should have been sent back to the RNs for corrections. The Administrator had no additional comments or documentation to correct findings. Review of agency policy TX.6 Plan of Care dated 8/22/17 read in part: After an appropriate assessment (evaluation) visit, the RN consults with the physician in developing the Plan of Care and obtains physician approval. Services are to be furnished according to a written plan of treatment determined by the physician…”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on interview and record review the agency failed to provide the written Notice of Medicare Noncoverage (NOMNC) in advance of terminating on-going care in 1 (Patient 6) of 3 discharge record reviewed, whose reason for discharge was goals met. The agency failed to protect the rights of the patient and failed to ensure the implementation of the agency’s discharge policy and procedures. The patient was unable to exercise their right to appeal the discharge decision and the failure potentially placed the patient at risk for disruptions in medical care and services. Record review of Patient #6 for period 06/14/2024-08/12/2024 contained a discharge summary with a discharge date of 8/11/2024 with goals met. The patient’s clinical records did not contain a NOMNC or documentation that a NOMNC was given or discussed with patient. An interview was conducted with the Interim DON on 01/03/2025 at 12:26pm The surveyor shared the findings that the written 2-day NOMNC was not present in Patient #6’s clinical records. The Interim DON stated that the agency scans, and uploads patient (or authorized representative) signed NOMNC forms to patient’s clinical records. The Interim DON confirmed the NOMNC form was not present in Patient #6 clinical records and provided no additional documentation or evidence to confirm the notice was provided prior to discharge. An interview was conducted with the Administrator on 01/06/2025 at 4:35pm. The surveyor shared the findings that the written 2-day NOMNC was not present in Patient #6’s clinical records. The Administrator stated that the agency’s policy was to deliver a 2-day NOMNC notice to the patient before discharge. The Administrator provided no additional documentation or evidence to correct the findings. Record review of Agency’s policy “PE.6 Patient Discharge” revision 05/06/16 read in part “Purpose- To allow patients to challenge/appeal their Agency’s decisions to discharge…Agency will deliver the generic CMS notice NOMNC…to the patient (or authorized representative), no less than (2) days prior to the day of anticipated discharge, or as soon as the Agency determines coverage will end.””

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on record review and interview the agency failed to document both the existence of a complaint regarding services and the resolution of the complaint for 1 (Confidential patient #8) of 1 record reviewed. Patients were subjected to continued poor care and poor health outcomes. Review of a complaint filed with the Texas Health and Human services on 05/13/2024 documented complaints made to the agency about the lack of nursing care to a confidential patient. The confidential complainant reported asking for a female nurse when male nurses were provided. The complainant documented a lack of consistent nursing care. The complainant documented the patient only felt comfortable being seen by women and that seemed always to be an issue. The complaint documented the agency would send a nurse, the nurse would show up maybe twice consecutively but then started not showing up. The complainant documented “We called and complained, and they tried to send a male nurse, and we had to tell them again the patient did not want to be seen by a man. The agency sent another female nurse who came a few times regularly but then stopped coming. We had to call to find out what was going on. The agency told us the nurse was sick, and they would find us someone else. The agency sent another nurse, and the same thing happened. The nurse came a few times then started not showing up. When I called the nurse and asked why she hadn’t come, the nurse stated the agency had new people and the nurse was reassigned. The nurse stated someone would reach out to me and that never happened. I called the past nurse again and told her that I had not heard from anyone. The nurse said she would find out and call me back. The complainant documented: that was over a week ago. This is the 3rd time this has happened and every time I never received a call back. I had to call the past nurses or the office. “ The surveyor requested the complaint logs during the entrance conference. Record review of all the agency provided complaint logs and investigation documents found no evidence of documentation of the complaints filed regarding lack of nursing care for Confidential Patient #8. Record review of the confidential Patient #8 revealed missed nursing visits with no evidence of a report to the physician who ordered the care. Clinical records for care were incomplete and not available for the surveyor to review. Patient #8 had a plan of care that ordered weekly nursing visits. An interview was conducted with the Interim DON on 01/03/2025 at 12:26 PM. The surveyor reviewed the record review findings and asked about complaints. The Interim DON stated they had some patients who preferred female nurses and “may have missed some visits if they didn’t have staff.” The Interim DON stated the previous DON, RN B should have documented the complaints about lack of nursing care. The Interim DON looked in her folder of complaints and stated she didn’t have any documentation regarding the missed visits. The surveyor asked about the incomplete clinical record. The Interim DON stated the records were in the old EMR BB clinical record documentation system. The Interim DON stated she did not have access to EMR BB. An interview with the Administrator on 01/06/2024 at 4:35 PM. The surveyor shared the findings about the lack of documentation of complaints regarding nursing care. The Administrator stated they should be documented and documented in the complaint and QA documents by the Interim DON. The male nurse would have been LVN A. The surveyor asked the Administrator to describe the procedure for complaints. The Administrator stated they “would have talked to scheduling and we would have discussed and staffed the missed visits. We try not to miss them.” The Administrator stated the documentation of the complaints should be there, why the visits were missed, and notification to the physician. Review of agency policy “RI.6 Resolution of Patient Conflicts, Grievances or Complaints” revision 8/31/16 read in part “ Agency will receive, address, and resolve complaints made by a patient, a patient’s family or guardian, or a patient’s health care provider…Procedure- Agency will document the receipt of the complaint and initiate a complaint investigation within ten (10) calendar days of Agency’s receipt of complaint. Management will be informed of the complaint.””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, record review and interview the agency failed to ensure the content of the comprehensive assessments for 3 (Identifiers 3,4 and 6) of 7 Patient records reviewed accurately reflected the patient’s status, patient’s current health, psychosocial, functional, and cognitive status. Without a complete assessment of the patient’s status the patients were subjected to poor care planning with the potential for poor health outcomes. Record review of Patient #3 revealed a comprehensive assessment signed by the Interim DON dated 11/27/2024. The assessment documented failed to document assessment of endocrine and psychosocial status. A further review of the patient’s record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The POC for Patient #3 dated 10/01/2024 to 11/29/2024 with a start of care date 12/06/2023 contained diagnoses: Quadripelgia (partial or total paralysis of the arms, hands, trunk, legs, and pelvic organs), Spastic Quadriplegic Cerebral Palsy (muscle contractions, stiffness and immobility affecting all 4 limbs) Neurogenic bladder (damage of nerves and muscles that control the bladder), Mood Disorder (serious mental illness that affects a person’s mood and behavior), Personal History of urinary tract disorder (infections of the urinary system). The POC failed to include psychosocial status. A home visit by the surveyor was made to Patient #3’s residence on 01/02/25 at 1:40 PM. The patient stated LVN A came once a month to change his urinary catheter. Patient #3 stated a nurse called him 11/27/24 to ask him some health questions. The patient stated the nurse did not come to the house and spoke with him on the telephone. Patient #3 stated he preferred only LVN A come to the house. Record review of Patient #4 revealed a Start of care comprehensive assessment signed by RN A for the start of care date of 03/16/2024. The assessment had many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #4 recertification comprehensive assessment for the certification period 05/15/2024 to 07/13/2024 signed by the Interim DON and dated 05/14/2024 revealed many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Patient #4s Plan of care dated 05/15/2024 to 07/13/2024 which stated the start of care was 05/15/2024 (not 03/16/2024) contained no diagnoses, Advance directives information, safety measures, mental /cognitive status, psychosocial status, neurological status, prognosis, nutritional requirements, caregiver status, prognosis, activities permitted, DME and supplies, no medications, no frequency and duration for nursing, services, goals, homebound status, potential, and discharge plan. Record review of Patient #4 recertification comprehensive assessment for the certification period 07/11/2024 to 09/11/2024 signed by the Interim DON and dated 07/11/2024 revealed many blank areas including: gastrointestinal and psychosocial status, Durable medical equipment information, and supplies. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Review of Patient #4s plan of care dated 07/14/2024 to 09/11/2024 which stated the start of care was 05/15/2024 contained Diagnoses of Hypertension (high blood pressure), Chronic Kidney Disease (longstanding disease of the kidneys that may lead to kidney failure), Migraine (debilitating headaches), and Dizziness (balance issues). The POC did not contain psychosocial status, Durable medical equipment information, and supplies needed. Record review of Patient #6 revealed a Start of care comprehensive assessment signed by RN C for the start of care date of 06/14/2024. The assessment had mostly blank areas including: Advance directives information, vital signs, vital sign parameters to report to the physician, past medical history, risk assessment, health screening, immunization history, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. The assessment had an attached document that was a printout of only the OASIS (a data collection tool used by Medicare-certified home health agencies to assess and report information on their patients at regular intervals that must be incorporated into an agency’s comprehensive assessment) required items. Patient #6’s comprehensive assessment failed to include wound measurements, or wound assessments. The assessment failed to incorporate all the OASIS data and the agency assessment data. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The Plan of care for Patient #6 dated 06/14/2024 to 08/12/2024 which stated the start of care was 06/14/2024 contained diagnoses of Hypertension (high blood pressure) and Type 2 Diabetes Mellitus (inability to regulate blood sugar.) The plan of care did not contain a diagnosis related to the wound care being provided or wound care orders. On a nurses note dated 06/19/2024 the Interim DON documented that the surgical wound was not healed. An interview was conducted with the Interim DON on 01/03/2025 at 12:26 PM. The surveyor reviewed the findings for Patient #6 and asked about the missing wound assessment. The Interim DON stated the wound assessment documentation was not downloaded from EMR BB, only the OASIS required contents out of the initial assessments. The surveyor reviewed the findings of the record reviews and incomplete comprehensive assessments for each patient. The Interim DON stated she had completed the assessments by telephone “since COVID (a world wide respiratory infection).” The surveyor asked why these visits were not done in person. The Interim DON stated: She did them by telephone “if we have nurses sick or patients that only want LVN A and won’t allow other nurses in the home.” The Interim DON stated she did the assessments by telephone due to patient or nurse illness when the comprehensive assessments were due and they didn’t have another nurse or DON to do them. The Interim DON stated she documented that the visits were by telephone in the patient records for most of the assessments done by telephone. The Interim DON stated she used clinical information from the LVN’s notes to complete the vital signs and other clinical information. The interim DON stated the wound care orders and supplies should be on Patient #1’s assessment and orders and “I just missed it.” The Interim DON stated she lived in Oklahoma and came to the metroplex several times per year. The interim DON stated she came in September 2024, and the last time was a “couple of weeks ago.” The Interim DON stated she did a telephonic comprehensive assessment for Patient #4 and just forgot to document the assessment “was telephonic.” The Interim DON stated most of the assessments were done in person but when they turned over the DON or were short staffed, she did them by telephone. The Interim DON stated the new EMR software AA used for documenting assessments and care “doesn’t work well.” The Interim DON stated the new EMR AA “lost narratives and wound assessments.” The surveyor asked why the assessments prior to July 2024 contained only the OASIS items and not all of the comprehensive assessment items. The Interim DON stated the Alternate Administrator was responsible for downloading records from the previous EMR into the new one, and if she only downloaded the M items (OASIS required items) then the assessments that were downloaded were incomplete. The Interim DON stated she could not access the previous EMR clinical records at this time. The Interim DON stated her position was normally as QAPI and she reviewed the assessments, clinical documentation, and contacted the patients by telephone and spoke with the nurses. The Interim DON stated she was the Interim DON when they turned over DON’s. An interview was conducted on 01/06/2025 at 4:10 PM with the Administrator. The surveyor shared the findings regarding comprehensive assessments being incomplete, inaccurate, and transmitted late. The Administrator stated she was aware of the late transmissions around the time of the agency’s change in electronic medical record vendor. The Administrator stated it “might have been an issue with the submitter ID being wrong” in the current electronic medical record system and “it was probably a software issue.” The Administrator stated the Alternate Administrator was not available for an interview as she was off due to a death in the family. The surveyor asked if the Administrator was aware of the comprehensive assessments by telephone. The Administrator stated she was aware. No additional information was provided to explain or clarify the findings. The surveyor explained the possible condition level deficiencies for comprehensive assessments to the Administrator. The Administrator stated she understood the issues. Agency policy PE.3 Initial Patient Comprehensive Assessment dated 01/01/2017 read in part: Policy – Each patient will receive a patient specific, comprehensive assessment which incorporates OASIS data set for Medicare/Medicaid patients, completed by a Registered Nurse … Each patient will receive a specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes… the assessment data will be collected utilizing the following methods: a. Interaction and interview with the patient/family/physician: b. Assessment using standardized, validated tools; and C. Observation and measurement utilizing the senses and calibrated instruments. 6. The Comprehensive Assessment will include but not be limited to the following: a. Physical assessment/Review of systems; OASIS data set for Medicare/Medicaid patients which would include pertinent diagnoses, prognosis, physical findings, medical history, etc.; AOL’s/Functional status; Medication history, including drug allergies, sensitivities and past adverse drug reactions; Food and environmental allergies; Psycho-social status; Residential environment; Nutritional requirements; Height, weight and BMI per Policy PE.8; and Agencies or companies supplying Out Patient services and/or medical supplies. Screens to identify patients who may require a more in-depth functional assessment by the appropriate discipline, including: Medical history; Problems/needs/strengths of the patient; Education needs of patient/family; Home environment; Any equipment; All medications and past medication compliance history; Patient’s family or support system and the care they are capable of providing and willing to provide; Preventive and periodic health screening; Depression or suicide risk; Pressure ulcer/injury risk; Identifying patients who are at moderate or high nutritional/hydration risk; Abuse; and Safety… Agency policy PE.4 Patient Reassessment … dated 01/01/2017 read in part: Each patient will be reassessed utilizing the recertification/ follow-Up Comprehensive Assessment during the last five (5) days of the episode (day 56-60)…””

“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 observation, record review and interview the plan of care for 4 (Identifiers 1,3,4, and 5) of 7 records reviewed failed to include all the required information for detailed individualized care. Lack of detailed, individualized, and accurate plans of care subjected patients to poor quality and potentially unsafe care. Record review of Patient #1 revealed a comprehensive assessment signed by the Interim DON dated 09/10/2024. The assessment documented: “Tele visit: Instructed PT/CG this is tele visit and that all assessments and vital signs obtained from PT/CG.” The assessment documented the patient with a history of pressure ulcers (bedsore- injury to skin and underlying tissue resulting from prolonged pressure on the skin) “that are now resolved.” A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The POC for Patient #1 dated 09/12/2024 to 11/10/2024 with a start of care date 09/10/2023 contained diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (in ability to regulate blood sugar that has damaged the nerves), Hypertension (high blood pressure), Chronic Pain syndrome (persistent pain that lasts weeks or years), Hypothyroidism (thyroid doesn’t produce enough thyroid hormone), Bed Confinement Status (patient is unable to tolerate activity outside of the bed), and Long term Use of Insulin (use of insulin over period of time which can negatively affect cardiovascular system). The POC failed to include a wound diagnosis, wound care orders, and wound care supplies. Review of nurses notes by LVN A documented wound care to the patients left buttock open surgical wound on visits dated 09/13/24, 09/16/24, 09/18/24, 09/20/24, 09/23/24, 09/25/24, 09/27/24, and 09/30/24, 10/02/2024, 10/04/2024, 10/07/2024, 10/09/2024, 10/11/2024, 10/14/2024, 10/16/2024, 10/18/2024, 10/21/2024, 10/23/2024, 10/25/2024, 10/28/2024, 10/30/2024, and 11/01/2024. The visit note dated 11/04/2024 was blank. Record review of Patient #1 revealed a comprehensive assessment signed by the Interim DON dated 11/08/2024. The assessment documented: “Tele visit: Instructed PT/CG this is tele visit and that all assessments and vital signs obtained from PT/CG… Wound care not performed” as this was not a scheduled dressing change day. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. On the same date, 11/08/2024 review of the clinical record found a nurses note by LVN A that documented wound care to the patients left buttock open surgical wound during the visit. A home visit by the surveyor was made to Patient #1’s residence on 01/02/25 at noon. The patient stated LVN A came Monday, Wednesday and Friday to change his wound on his left buttocks. The patient stated LVN A had come since the client was discharged from the hospital and provided wound care. The patient stated the RN did not come to the house on 09/11/2024 and 11/08/2024 but talked with him on the telephone. Patient #3 stated he preferred only LVN A come to the house. Record review of Patient #2 revealed a comprehensive assessment signed by the Interim DON dated 11/07/2024. The assessment documented this was a “tele visit” due to staff and patient with flu-like symptoms with vital signs obtained from the patients records and conversation with the patients. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The POC for Patient #2 dated 11/12/2024 to 01/10/2025 with a start of care date 07/15/2024 contained diagnoses: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (inability to regulate blood sugar that has damaged the kidneys), Hypertension (high blood pressure), Ashma (breathing disorder causing wheezing, coughing and shortness of breath), Hypothyroidism (thyroid doesn’t produce enough thyroid hormone), and Hyperparathyroidism (excess of hormone by the parathyroid gland). The POC was missing blood sugar parameters to report to the physician. The surveyor attempted to make a home visit to Patient #2 on 01/02/205 at 1PM. There was no answer to door or telephone. Record review of Patient #3 revealed a comprehensive assessment signed by the Interim DON dated 11/27/2024. The assessment documented failed to document assessment of endocrine and psychosocial status. A further review of the patient’s record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The POC for Patient #3 dated 10/01/2024 to 11/29/2024 with a start of care date 12/06/2023 contained diagnoses: Quadriplegia (partial or total paralysis of the arms, hands, trunk, legs, and pelvic organs), Spastic Quadriplegic Cerebral Palsy (muscle contractions, stiffness and immobility affecting all 4 limbs) Neurogenic bladder (damage of nerves and muscles that control the bladder), Mood Disorder (serious mental illness that affects a person’s mood and behavior), Personal History of urinary tract disorder (infections of the urinary system). The POC failed to include psychosocial status. A home visit by the surveyor was made to Patient #3’s residence on 01/02/25 at 1:40 PM. The patient stated LVN A came once a month to change his urinary catheter. Patient #3 stated a nurse called him 11/27/24 to ask him some health questions. The patient stated the nurse did not come to the house and spoke with him on the telephone. Patient #3 stated he preferred only LVN A come to the house. Record review of Patient #4 revealed a Start of care comprehensive assessment signed by RN A for the start of care date of 03/16/2024. The assessment had many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #4 recertification comprehensive assessment for the certification period 05/15/2024 to 07/13/2024 signed by the Interim DON and dated 05/14/2024 revealed many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The Plan of care dated 05/15/2024 to 07/13/2024 which stated the start of care was 05/15/2024 (not 03/16/2024) contained no diagnoses, Advance directives information, safety measures, mental /cognitive status, psychosocial status, neurological status, prognosis, nutritional requirements, caregiver status, prognosis, activities permitted, DME and supplies, no medications, no frequency and duration for nursing, services, goals, homebound status, potential, and discharge plan. Record review of Patient #4 recertification comprehensive assessment for the certification period 07/11/2024 to 09/11/2024 signed by the Interim DON and dated 07/11/2024 revealed many blank areas including: gastrointestinal and psychosocial status, Durable medical equipment information, and supplies. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Review of Patient #4s plan of care dated 07/14/2024 to 09/11/2024 which stated the start of care was 05/15/2024 contained Diagnoses of Hypertension (high blood pressure), Chronic Kidney Disease (longstanding disease of the kidneys that may lead to kidney failure), Migraine (debilitating headaches), and Dizziness (balance issues). The POC did not contain psychosocial status, Durable medical equipment information, and supplies needed. Record review of Patient #6 revealed a Start of care comprehensive assessment signed by RN C for the start of care date of 06/14/2024. The assessment had mostly blank areas including: Advance directives information, vital signs, vital sign parameters to report to the physician, past medical history, risk assessment, health screening, immunization history, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. The assessment had an attached document that was a printout of only the OASIS (a data collection tool used by Medicare-certified home health agencies to assess and report information on their patients at regular intervals that must be incorporated into an agency’s comprehensive assessment) required items. Patient #6’s comprehensive assessment failed to include wound measurements, or wound assessments. The assessment failed to incorporate all the OASIS data and the agency assessment data. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. The Plan of care for Patient #6 dated 06/14/2024 to 08/12/2024 which stated the start of care was 06/14/2024 contained diagnoses of Hypertension (high blood pressure) and Type 2 Diabetes Mellitus (inability to regulate blood sugar.) The plan of care did not contain a diagnosis related to the wound care being provided or wound care orders. On a nurses note dated 06/19/2024 the Interim DON documented that the surgical wound was not healed. An interview was conducted with LVN A on 01/03/2025 at 11:50 AM. LVN A stated he provided wound care three times a week to Patient #1. LVN A stated he saw Patient #3 monthly for catheter changes. An interview was conducted with the Interim DON on 01/03/2025 at 12:26 PM. The surveyor reviewed the findings of the record reviews and missing items on the plans of care. The Interim DON reviewed the records and stated the items should be on the POC’s. The surveyor asked why the clinical records had missing and incomplete clinical documents. The Interim DON stated the agency had changed from EMR BB in July 2024. The DON stated the agency switched to a new electronic medical record system EMR AA in July 2024 and clinical records “disappeared.” The Interim DON stated she did not have access to records from EMR BB. The Interim DON stated the Alternate Administrator scanned some of the clinical documents from EMR BB to EMR AA during the transition. The Interim DON stated clinical records continue to disappear in EMR AA even when they h..ave have been downloaded. The Interim DON stated this was a fairly common occurrence since the agency changed to EMR AA. An interview was conducted on 01/06/2024 with RN B, the previous DON at 4:01pm. The surveyor asked about the plans of care being incomplete for Patient #4. RN B stated she couldn’t remember and had no access to the records. RN B stated there were not enough staff, she had to do visits, starts of care, and office work. RN B stated she dropped down from DON to field nurse, then left in November, 2024. An interview was conducted on 01/06/2025 at 4:10 PM with the Administrator. The surveyor shared the findings regarding clinical records reviews and missing information on the plans of care. The Administrator stated POC was the responsibility of the RN who does the assessment, then they go to QAPI for review, then the DON was responsible for the final review. The Administrator stated one of the problems was they want to help the nurses and make them get it correct, but the nurses get mad. These should have gone back to the RN to correct, then they can check the order and the plan of care. Agency policy TX.6 Plan of Care dated 08/22/2017 read in part: Purpose- To develop an Individualized Plan of Care to ensure patient specific needs are met appropriately and according to state and federal regulations. Policy -A. Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and /or needs... Services are to be furnished according to a written plan of treatment determined by the physician after any needed consultations with the qualified therapist and signed and dated by the physician after an appropriate assessment (evaluation) of the condition is completed… The Plan of Care, which includes the following elements, is developed in consultation with staff, patient, caregiver, physician and other providers involved in the patient’s care…Patient’s primary and secondary diagnoses; Food, drug allergies and environmental allergies as applicable; Goals/outcomes to be achieved; Mental status; Functional / structural limitations; Activities permitted; Safety measures to protect against injury; Nutritional requirements; List of current medications including name, strength, dose, route, and frequency for each and indication of use for all PRN medications: N or C may be used to indicate new or changed medications; Physician orders to include the discipline to render the services/ treatments, the services or therapy modalities to be rendered and the frequency and duration of the visits to be made; to specific procedures/treatments to be performed, including amount, frequency and duration; Types of supplies and equipment required in the provision of care; Discharge instructions or plan; …As applicable to care: Diabetic foot care including monitoring for presence of skin lesion on the lower extremities and education on proper foot care; Fall prevention interventio1 Depression interventions such as medication, referral for other treatment, or a monitor plan for current treatment; Interventions to monitor and mitigate pain; Interventions to prevent pressure ulcers; and Pressure ulcer treatment based on principles of moist wound healing; … modifications to the care plan are indicated by: reassessments, patient condition/needs, change in orders, and/or achievement of identified goals. These are documented either on discipline progress notes or a physician verbal order. The care plan is reviewed and/or revised, with physician participation, at least every 60 days.”

“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 interviews and record reviews the agency’s skilled nurses failed to communicate with the physicians or practitioners involved in the plan of care for 5 (Patient 2,4,5,6,7) of 7 patients records reviewed. This failure places patients at risk of not receiving necessary medical interventions which could result in negative client health outcomes. Record review of Patient #2 for period 11/12/2024-01/10/2025 revealed a plan of care signed by RN A on 11/07/2024 for dates of 11/12/2024 to 01/10/2025. The plan of care ordered weekly skilled nurse visits and stated to notify physician of vital sign parameters out of range: Pain scale greater than 5 out of 10. Skilled nurse visit notes dated 12/13/2024 and 12/21/2024 and signed by LVN B revealed the patient’s pain was 6 during the assessments. The nurse notes contained a section for documentation of care coordination with the physician and this area was checked marked as N/A (not applicable). Review of the patient’s records failed to find any documentation the physician was notified of the patient’s elevated pain levels. Record review of Patient #4 for period 03/16/2024-05/14/2024 revealed a start of care comprehensive assessment signed by the Interim DON for the start of care date of 03/16/2024. The assessment contained a section for documentation of care coordination with the physician and this area was blank. Review of the patient’s records failed to find any documentation of coordination of care with the physician during the start of care. Record review of Patient #4 for period 7/14/2024- 9/11/2024 revealed a plan of care signed by RN A for dates 7/14/2024 to 9/11/2024. The plan of care did not list the nurse frequency. Missed visits notes dated 7/24/2024 and 7/31/2024 contained a blank comment section. Patient #4’s records contained no documentation of the reason for the missed visits and no notification to the physician of the missed visits. Record review of Patient #5 for period 7/29/2024-9/26/2024 revealed a start of care comprehensive assessment dated 7/29/2024 and signed by RN B. The assessment contained a section for documentation of care coordination with the physician and this area was blank. The plan of care signed by RN B for dates 7/29/2024 to 9/26/2024 did not list the nurse frequency. A missed visit note dated 8/6/2024 contained a blank comment section. Patient #5’s records contained no documentation of the reason for the missed visit and no notification to the physician of the missed visit. Record review of Patient #6 for period 6/14/2024-8/12/2024 revealed a plan of care signed by the DON for dates 6/14/2024 to 8/12/2024. The plan of care ordered nurse visits twice a week effective 6/16/2024 then weekly effective 6/30/2024. Nurse missed visit notes dated 7/23/2024 and 8/01/2024 contained blank comment sections. Records revealed no documentation of a nurse visit made during the period of 7/17/2024 thru 8/5/2024. Patient #6’s records contained no documentation of the reason for the missed visits and no notification to the physician of the missed visits. Record review of Patient #7 for period 10/23/2024-12/21/2024 revealed a plan of care signed by RN A on 10/22/2024 for dates 10/23/2024 to 12/21/2024. The plan of care ordered weekly skilled nurse visits and stated to notify physician of vital sign parameters out of range: Pain scale greater than 5 out of 10. A recertification assessment completed 10/22/2024 and signed by RN A revealed patient’s pain 8 out of 10 during the assessment. Review of the patient’s records failed to find any documentation the physician was notified of the patient’s elevated pain level. An interview was conducted with LVN B on 1/03/2025 at 1:51 pm. The surveyor shared the findings of Patient #2’s pain of 6 on 12/13/2024 and 12/21/2024. The nurse notes contained a section for documentation of care coordination with the physician and this area was marked as N/A (not applicable). LVN B stated that the physician was aware that the patient had pain, but she could not confirm if the physician was notified on 12/13/2024 and 12/21/2024 for pain greater than 5 as directed in the plan of care. LVN B provided no additional documentation or evidence to correct the findings. An interview was conducted with the Supervising Nurse (Interim DON) on 1/03/2025 at 12:26pm. The surveyor shared the findings of events with no evidence of communication with the physician or practitioner for Patients 2,4,5,6, and 7. The Interim DON confirmed that no communication notes or documentation were present in the patient’s records, that the physician for Patient #2 (visit date 12/13/2024 and 12/21/2024) and Patient #7 (visit date 10/22/2024) was notified of the patient’s pain greater than 5 during the nurse visits. The Interim DON stated that the agency’s procedure was is to contact the doctor and completed a communication note when the patient’s pain is out of parameters. The Interim DON confirmed the patient’s clinical records contained no documentation of the reason for the missed nurse visits and no notification to the physician of the missed visits for Patient # 4 (7/24/2024 and 7/31/2024), Patient #5 (8/6/2024) and Patient #6 (7/23/2024 and 8/01/2024). The DON informed the surveyor that prior to the implementation of the new clinical record software, communication notes were entered on missed visits and sent to the physician. The Interim DON reported the process of entering communication notes stopped when the agency switched to a new software in July 2024. The Interim DON provided no additional documentation or evidence to correct the findings. An interview was conducted with the Administrator on 01/06/2025 at 4:35pm. The surveyor shared the findings of events with no evidence of communication or coordination of care with the physician or practitioner for Patients # 2,4,5,6,7. The Administrator stated that the agency tried to not miss visits, and the agency’s procedure was to document on a communication note why the visit was missed and document the notification of the doctor. The Administrator had no additional comments on the coordination of care between the agency nurses and physicians. The Administrator provided no additional documentation or evidence to correct the findings. Record review of Agency’s policy titled “Monitoring Patient Care/Coordination of Care TX.8 Revised date: 11/15/13” read in part “Agency will assess, evaluate and report the patient’s status and progress towards achieving goals established on the plan of care to the physician.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure all required items including the patient’s current comprehensive assessment, including all the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders were in the clinical record for 7 (Identifier 1,2,3,4,5,6, and 7) of 7 records reviewed. The agency did not provide access to complete client records prior to July 2024. Patient care and patient rights were potentially at risk due to the lack of complete records. During the entrance conference on 12/31/2024 the surveyor requested agency clinical records access. The agency provided access to EMR AA. Review of Client records in EMR AA found incomplete clinical records were downloaded from the previous EMR BB. Complete client records were not available for the agency patient prior to July 2024. The surveyor requested access to the previous EMR BB in writing via email on January 2 at 4:46PM. The surveyor explained to the Administrator the lack of access to all active and discharged clinical records for the three-year survey period from (December 31, 2021, to the end of the survey) was delaying the survey. The surveyor requested the telephone number and contact person for the previous EMR BB on 01/03/2025 and an explanation about why no access to the clinical records had been provided. Record review of Patient #1 revealed a comprehensive assessment signed by the Interim DON dated 09/10/2024. The assessment documented: “Tele visit: Instructed PT/CG this is tele visit and that all assessments and vital signs obtained from PT/CG.” The assessment documented the patient with a history of pressure ulcers (bedsore- injury to skin and underlying tissue resulting from prolonged pressure on the skin) that are now resolved.” A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #1 revealed a comprehensive assessment signed by the Interim DON dated 11/08/2024. The assessment documented: “Tele visit: Instructed PT/CG this is tele visit and that all assessments and vital signs obtained from PT/CG… Wound care not performed” as this was not a scheduled dressing change day. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s accurate current status and needs. Record review of Patient #2 revealed a comprehensive assessment signed by the Interim DON dated 11/07/2024. The assessment documented this was a tele visit due to staff and patient with flu-like symptoms with vital signs obtained from the patients records and conversation with the patients. A review of the patients record failed to find a completed comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #3 revealed a comprehensive assessment signed by the Interim DON dated 11/27/2024. The assessment documented failed to include assessment of endocrine and psychosocial status. A review of the patients record failed to find a completed accurate comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #4 revealed a Start of care comprehensive assessment signed by RN A for the start of care date of 03/16/2024. The assessment had many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed accurate comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #4 recertification comprehensive assessment for the certification period 05/15/2024 signed by the Interim DON and dated 05/14/2024 revealed many blank areas including: Advance directives information, primary language, vital signs, vital sign parameters to report to the physician, past medical history, health screening, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. A review of the patients record failed to find a completed accurate comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #4 recertification comprehensive assessment for the certification period 07/11/2024 signed by the Interim DON and dated 07/11/2024 revealed many blank areas including: gastrointestinal and psychosocial status, Durable medical equipment information, and supplies. A review of the patients record failed to find a completed accurate comprehensive assessment with all required elements that reflected the patient’s current status and needs. Record review of Patient #5 clinical record revealed no orders or coordination notes for missed visits on 08/06/2024, an incomplete Plan of Care without a frequency for nurse visits, and a start of care comprehensive assessment without coordination with the physician. Record review of Patient #6 revealed a Start of care comprehensive assessment signed by RN C for the start of care date of 06/14/2024. The assessment had mostly blank areas including: Advance directives information, vital signs, vital sign parameters to report to the physician, past medical history, risk assessment, health screening, immunization history, supportive assistance received, safety / Sanitation hazards, safety measures, emergency disaster plan and triage code, hearing, speech, and vision assessment, pain assessment, skin assessment, respiratory and cardiac status, endocrine, gastrointestinal, and elimination status, swallowing, and nutrition status and requirements, psychosocial status, suicide and depression screening, functional abilities and goals, Activities permitted, Durable medical equipment information, supplies, fall risk assessment, prognosis, homebound status, and needs for special treatments, procedures and programs including therapy need. The assessment blank areas also included skilled interventions, patient identified strengths and care preferences, rehab potential, and discharge plan and goals. The assessment had an attached document that was a printout of only the OASIS (a data collection tool used by Medicare-certified home health agencies to assess and report information on their patients at regular intervals that must be incorporated into an agency’s comprehensive assessment) required items. Patient #6’s record contained a comprehensive assessment that failed to include wound measurement, and the assessment failed to incorporate all the OASIS data and the agency assessment data. A review of the patients record failed to find a completed accurate comprehensive assessment with all required elements that reflected the patient’s current status and needs. Review of the clinical record for Patient #7 found the last update to the comprehensive assessment was documented on 10/22/24 by RN A. RN A documented the last clinical note in the record which was skilled nurse visit note on 10/29/2024. The 10/29/2024 nurses’ note documented no discharge planning or notice to the patient. The nurses note dated 10/29/2024 documented the plan for the next visit was “Monitor/Assess and Continue review of all medications.” The record contained no other notes after 10/29/2024. Patient #7’s record contained no update to the comprehensive assessment at discharge. Review of the emails provided by the Administrator on 01/03/2025 revealed: The Administrator requested access from EMR CC representative on 01/02/2025 at 9:45 PM. The EMR CC representative replied on 01/03/2025 that they could not give access until the “bad debt is paid off to the collection agency. The total amount is $25,152.24. Once that is paid off then the agency would have to sign a read only agreement and pay the amount for that service.” The Administrator replied on 01/03/2025 “I do not have $25k to pay today and the surveyor is here. Can we work out a payment plan?” The EMR CC representative replied on 01/03/2025 at 9:49 AM “We can not as you would have to go through the collection agency.” An interview was conducted on 01/03/2025 at 12:26 PM with the Interim DON. The surveyor asked why the clinical records had missing and incomplete clinical documents. The Interim DON stated the agency had changed from EMR BB in July 2024. The DON stated the agency switched to a new electronic medical record system EMR AA in July 2024 and “records of transmitting and visits disappear.” The Interim DON stated the Alternate Administrator scanned some of the clinical documents from EMR BB to EMR AA during the transition. The Interim DON stated clinical records continue to disappear in EMR AA even when they have been downloaded. The Interim DON stated this was a fairly common occurrence since the agency changed to EMR AA. The surveyor reviewed the findings of the record reviews and inaccurate and incomplete comprehensive assessments for each patient. The interim DON stated the wound and PICC care orders and supplies should be on Patient #1’s assessment and orders and “I just missed it.” The Interim DON stated she did a telephonic comprehensive assessment for Patient #4 and just forgot to document it was telephonic.” The Interim DON stated The Interim DON stated most of the assessments were done in person but when they turned over the DON or were short staffed, she did them by telephone. The Interim DON stated the new EMR AA system used for documenting assessments and care “doesn’t work well.” The Interim DON stated the new EMR AA “lost narratives and wound assessments.” The Interim DON stated the Alternate Administrator was responsible for downloading records from the previous EMR BB into the new one, and if she only downloaded the M items (OASIS required items) then the assessments would be incomplete. The Interim DON stated they could not access the previous EMR BB clinical records at this time. An interview was conducted on 01/06/2024 with the Administrator at 4:10 PM. The surveyor reviewed the findings regarding the failure to provide access to clinical records the agency must maintain. The Administrator stated she would eventually make a payment arrangement with EMR BB so the agency would have access to the clinical records. The surveyor was not provided access to the clinical records stored in the EMR BB system before July 2024 by the end of the survey 01/06/2025. Clinical records prior to July 2024 were incomplete or blank. Agency policy Medical Record Forms and Format IM.7 revised 09/08/2012 read in part: Policy – Agency will maintain active and inactive medical records in a format that facilitates easy retrieval of data/information. Agency will maintain standardized medical record forms as well as a format, for documenting all care provided to patients, which are organized for easy retrieval of data. Agency policy Medical Record Information Retention and Destruction IM.13 revised 03/16/2011 read in part: Purpose – To ensure medical record information retention and destruction is in accordance with federal and state laws and regulations. Policy – Agency will retain all adult medical records for a minimum of ten (10) years after discharge of the patient… Inactive patient information stored in a computer data system will be protected from accidental deletion and remain accessible to identified staff during normal working hours… • Agency policy PE.3 Initial Patient Comprehensive Assessment dated 01/01/2017 read in part: Policy – Each patient will receive a patient specific, comprehensive assessment which incorporates OASIS data set for Medicare/Medicaid patients, completed by a Registered Nurse … Each patient will receive a specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes… the assessment data will be collected utilizing the following methods: a. Interaction and interview with the patient/family/physician: b. Assessment using standardized, validated tools; and C. Observation and measurement utilizing the senses and calibrated instruments. 6. The Comprehensive Assessment will include but not be limited to the following: a. Physical assessment/Review of systems; OASIS data set for Medicare/Medicaid patients which would include pertinent diagnoses, prognosis, physical findings, medical history, etc.; AOL’s/Functional status; Medication history, including drug allergies, sensitivities and past adverse drug reactions; Food and environmental allergies; Psycho-social status; Residential environment; Nutritional requirements; Height, weight and BMI per Policy PE.8; and Agencies or companies supplying Out Patient services and/or medical supplies. Screens to identify patients who may require a more in-depth functional assessment by the appropriate discipline, including: Medical history; Problems/needs/strengths of the patient; Education needs of patient/family; Home environment; Any equipment; All medications and past medication compliance history; Patient’s family or support system and the care they are capable of providing and willing to provide; Preventive and periodic health screening; Depression or suicide risk; Pressure ulcer/injury risk; Identifying patients who are at moderate or high nutritional/hydration risk; Abuse; and Safety…”