Elite Home Health

“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 code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 146 of 896 assessments submitted. (16.18%) The agency did not code and electronically submit 146 patients OASIS data to IQIES (electronic system used to transmit quality measures from OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patients health while admitted to home health services to ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being available to CMS for analysis of patient care performance. Findings included: Record review of an IQIES Error Summary Report dated 06/09/2025-06/09/26 generated by the surveyor on 06/09/2026 indicated the agency failed to code and electronically transmit 146 of 896 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 6/10/2026 at 10:58 a.m., Contracted Staff A said she was contracted to submit OASIS assessments for the agency and had done so for about 4 years. Contracted Staff A said over the past couple of years the agency had some difficulty with OASIS submissions, administrative staff and electronic medical record systems. She said since the new administrator and medical record system had been in place timeliness of submissions had improved. During an interview on 6/10/2026 at 11:45 a.m., the Administrator said the recent late OASIS submissions happened due to a change they made in their electronic medical record system. The administrator said the new system caused them to have difficulty getting things submitted timely. The Administrator said the agency changed electronic medical records once again and were hoping to continue with timely submissions so that data could be properly tracked on each patient. Record review of a policy dated 01/01/2026 titled Timelines indicated II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with Federal Information Processing Standard from the agency or the agencies contractor to the CMS collection site within 30 days of the MOO90 (date the assessment is completed) date.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the agency’s Governing Body failed to ensure that the Agency developed, implemented and maintained a Quality Assessment Performance Improvement program to ensure that an ongoing program for quality improvement and patient safety was defined implemented and maintained for 2 of 3 years reviewed. (2023 and 2024) The agencies QAPI meeting failed to meet twice per year in 2023 and 2024. This failure limited the agency’s ability to review client outcomes and to identify and immediately correct any problems which might threaten the safety and care of the clients. Findings included: Record review of the agency’s undated QAPI binder indicated meetings were held on 2/28/25 and 7/28/2025. The QAPI binder gave no indication that the agency conducted any QAPI meetings for calendar year 2023 or 2024. During an interview on 6/10/2026 at 9:50 a.m., the Administrator said she was over QAPI. She said the agency held QAPI meetings at least once a year per policy but was not aware regulation was to meet twice per year. The Administrator said she started with the agency in August of 2024 and was unable to locate any previous QAPI documentation. During an interview on 6/10/2026 at 11:45 a.m., . The administrator said it was important to hold QAPI meetings twice a year to review and identify all trends and information that can be improved upon and things are updated as needed. During an interview on 6/10/2025 at 12:15 pm, the owner/Alternate Administrator said the Administrator / DON was responsible for all QAPI activities. Record review of a policy dated 04/14/23 titled Quality Assessment Performance Improvement Program-Addendum indicated C. The QAPI committee will meet twice a year or more often if needed and will maintain a written record of meetings with appropriate signatures.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on interview and record review the agency failed to ensure clients were free from neglect for 1 of 11 patient records reviewed. (Patient #11) The agency did not report an allegation of neglect when Patient #1 reported RN A did not perform her skilled nurse visit, RN A completed the skilled nurse note and admitted to the Administrator she did not actually see Patient #1. This failure had the potential to place the agency’s Patients at risk for further abuse, neglect and exploitation and prevents HHSC from doing timely investigations. Findings included: Record review of a plan of care dated 05/21/2024-07/19/2024 indicated Patient #11 was admitted on 5/21/2024 and had diagnoses of chronic pain, atrial fibrillation (irregular heartbeat), high blood pressure, congestive heart failure(chronic heart condition), chronic kidney disease and diabetes (high blood sugar). The plan of care indicated Patient #11 was to have skilled nursing every other week for 5 weeks. Record review of a Patient/Client Complaint Form indicated the complaint was received on 8/8/2024 by the Administrator. Patient #11 reported RN A did not come to see her, even though she had been home all day, and RN A documented that she had seen the Patient. The form indicated the Administrator reviewed the nurse note submitted by RN A, spoke again with Patient #11 who had her neighbor verify no one had come to see her. The complaint form indicated RN A admitted she had falsely documented a visit and did not see the Patient. The complaint form indicated RN A was terminated and the visit was made non-billable. The form indicated Patient #11 verbalized she was happy with new nurse coming to her home on 8/22/2024. During an interview on 06/08/2026 at 3:35 p.m., the Administrator / DON said RN A was terminated following the complaint from Patient #11. The Administrator / DON said the visit RN A falsified was non-billed. The Administrator / DON said the agency did notify HHSC of allegations of abuse, neglect and exploitation, but at the time of the incident she did not think of it as abuse, neglect or exploitation. The Administrator said Patient #11 was not seen that day or week and a new nurse was sent to her home on 8/22/2024 because that was when Patient #11 would allow them to send anther nurse to her home. During an interview on 06/08/2026 at 4:45 p.m., RN A said she was terminated from the agency a couple of years ago but could not recall the date. She said she was terminated for not completing a home visit which was assigned to her. RN A said she did go to Patient #11’s home and she did not answer the door. RN A said Patient #11 had told her in the past if she did not answer the door when the nurse arrived she may be asleep and nurse could open the door and yell for her. RN A said she did open the door to yell for her but got no response. RN A said she called Patient #11’s phone and left a message for her to return her call to reschedule the visit. RN A said she did not falsify a skilled visit for that day in the Patients chart but was terminated because the Patient said she did not show up for the visit. During an interview on 6/10/2026 at 9:39 a.m., the Administrator/DON said RN A said she walked into Patient #11’s home and found her to be asleep and said she did not wake up for the visit and RN A admitted to actually completing the skilled nurse note for the visit. The Administrator /DON said both Patient #11 and her neighbor said RN A did not come to the home at all to provide care. During an interview on 6/10/2026 at 10:50 a.m., Patient #11 said she had been a Patient of the agency several years ago. Patient #11 said she did not recall exactly what happened but did recall calling the agency because she thought a nurse was coming to her home that day and she had not shown up after she was home all day. Patient #11 could not recall when a nurse came to her home after that but did recall they had sent a new nurse. Patient #11 said she did not recall the details of this incident. During an interview on 6/10/2026 at 11:45 a.m., the Administrator / DON said RN A neglected to see Patient #11 and the incident should have been reported to HHSC within 24 hours. The Administrator /DON said RN A submitted a written statement in which she admitted to documenting and completing the home visit with Patient #11 without actually seeing Patient #11 that day. The Administrator / DON said the visit RN A completed that day had to be removed from the electronic medical record so that a missed visit could be put in and the visit could be non-billed to CMS. She said RN A was terminated from the agency on 8/9/2024 but termination paperwork and RN A’s written statement were submitted to the human resources employee at the time to file in RN A’s personnel file but this was not done, and that human resources employee was no longer employed by the agency. The Administrator / DON said it was important to report any allegation of abuse, neglect or exploitation to HHSC within 24 hours because it was regulation and the Patients right. During an interview on 6/10/2026 at 12:15 p.m., the owner/Alternate Administrator said this incident should have been reported to HHSC as required. He said they immediately called the nurse in, investigated and terminated her after she admitted to falsifying the visit note. . He said he did not know why they did not report at that time to HHSC. He said the Administrator/DON would be the one responsible for reports made to HHSC. Record review of a policy dated 05/01/24 titled Abuse, Neglect, and Exploitation indicated II any agency staff, whether employed directly or under arrangement, in the normal course of providing services to patients/clients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of an unknown source or misappropriation of patient/client property, must report immediately to the agency and other appropriate authorities in accordance with state law. The policy indicated Agency management would D. Report if there is cause to believe abuse or neglect of a patient/client, or misappropriation of patient/client property, has occurred by a staff member or contractor to the appropriate authorities or state agencies immediately. The policy indicated Immediately means reporting without delay. The interim time between discovery and reporting an incident may be influenced by the individual situation. However, the reporting must be accomplished as soon as possible following the discovery.”

“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 interviews and record reviews, the agency failed to ensure the plan of care contained the required elements to cover all supplies and equipment required, patient specific interventions and education, and safety measures to protect against injury for 3 of 11 patients reviewed for plan of care. ( Patient #4, Patient #5 and Patient #6) The plan of care did not included bleeding precautions for Patient #4 and Patient #6 who had blood thinners ordered. The plan of care did not include sharps precautions for Patient #5 who had finger stick blood sugars ordered. This failure could place patients at risk of injury, improper care and instruction leading to complications and hospitalization. Findings included: Record review of a plan of care dated 5/23/2026-7/21/2026 indicated Patient #4 was admitted on 9/25/2025 and had diagnoses including orthostatic hypotension(sudden drop in blood pressure), hyponatremia(low sodium in the blood), high blood pressure, chronic kidney disease, congestive heart failure (chronic heart condition and long-term use of aspirin (blood thinner). The plan of care indicated skilled nursing saw Patient #4 once a week for nine weeks. The plan of care indicated Patient #4 took Aspirin 81 mg one tablet daily. The plan of care did not include bleeding precautions or teaching. Record review of a plan of care dated 6/1/2026-7/30/2026 indicated Patient #6 was admitted on 6/6/2025 and had diagnoses including venous insufficiency (leg veins struggle to return blood to the heart), lymphedema (excess fluid builds up in the body tissues causing abnormal swelling), high blood pressure, stage 5 kidney disease, end stage renal disease, diabetes (high blood pressure), and long-term use of aspirin. The plan of care indicated that skilled nursing saw Patient #6 once a week for nine weeks. The plan of care indicated Patient #5 took Aspirin 325 mg one tab daily. The plan of care did not include bleeding precautions or teaching. Record review of a plan of care dated 4/17/2026-6/15/2026 indicated Patient #5 was admitted on 4/17/2026 with diagnoses including chronic inflammatory demyelinating polyneuritis (autoimmune disorder, immune system attacks the myelin sheath protecting peripheral nerves), stage 4 pressure ulcer of the sacrum(skin and tissue damage over the tailbone), high blood pressure, and diabetes (high blood sugar). The plan of care indicated skilled nursing saw Patient #5 three times per week for one week then twice per week for seven weeks. The plan of care indicated the skilled nurse would check a fasting or random blood sugar at each skilled nurse visit and report a blood sugar greater than 250 or less than 60. The plan of care did not include sharps precautions. During an interview on 6/10/2026 at 11:08 a.m., RN B said she worked in the field and completed OASIS assessments. She said if a Patient was on any type of blood thinner they should have bleeding precautions as well as teaching related to bleeding precautions on their plan of care. RN B said Patient #4 and Patient #6 had been on Aspirin for awhile so should have had the precautions and teaching on their plan of care. RN B said any Patient receiving any type of blood draw or injection should have sharps precautions on their plan of care. She said Patient #5 had diabetes and orders for blood sugar checks and should have sharps precautions on her plan of care. RN B said it was important for the plan of care to have all of the appropriate elements and precautions because patient/Patient safety was the number one priority. During an interview on 6/10/2026 at 11:45 a.m., the Administrator/DON said she was responsible for reviewing all plan of cares for the agency once submitted from the field nurses. The Administrator/DON said she typically did put bleeding precautions and teaching on the plan of care for Patients who received 325 mg of Aspirin but had quit putting those precautions and teaching if the Patient only received 81 mg of Aspirin. The Administrator said any Patient on services who had orders for blood sugar monitoring should have sharps precautions on the plan of care. The Administrator said the Patient’s #4, #5 and #6 should have had these precautions on their plan of care. The Administrator/DON said these things were important so that every nurse and other disciplines seeing the Patients knew what to be careful with, what to watch for in each home and what to teach at each visit. Record review of an article accessed on 6/14/2026 7 Aspirin Side Effects You Should Know About - GoodRx indicated serious Aspirin side effects include stomach ulcers, kidney problems, and unusual bleeding or bruising. Record review of a policy dated 01/01/2026 titled Plan of Care indicated A. The individualized plan of care must include the following: 11. Safety measures to protect against injury.”