Centerwell Home Health

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide patients with the state toll free home health telephone hotline to patients on admission in 7 out of 7 patient admission packets reviewed (Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure resulted in patients not having easy access to the state hotline number, and potentially not being able to report the agency for abuse, neglect, exploitation, or to file other complaints. Findings included: On 1/27/26, at 10:30 AM, the Surveyor requested the Admission Packet and all other documents provided to patients on admission. A folder was given to the surveyor containing these documents. Record review of this folder did not reveal information on how to file a complaint with the state toll-free home health telephone hotline. The Surveyor was unable to find the hotline number in the Admission Packet. Review of the page 4 of the packet labeled, “My Home Health Resources Book,” revealed a table with multiple contact numbers and reasons to call. Under the box “Reason” it listed, “Report a complaint about [Agency 1]. Report the local [Agency 1]’s implementation of your advanced directives (if any). Request information about home health providers.” Next to that, in the box labeled, “Resource” it lists “State Home health hotline number”. Next to that, there is a box labeled, “Contact information.” This box was left blank. During an observation in the home of Patient 6 at 11:00 AM on 1/28/26, the surveyor reviewed the documents provided to the patient on admission. The State Hotline number was not provided. There was an empty box for “State home health hotline number” but no phone number was provided. During an observation in the home of Patient 12 at 12:30 PM on 1/28/26, the surveyor reviewed the documents provided to the patient on admission. The State Hotline number was not provided. There was an empty box for “State home health hotline number” but no phone number was provided. During an observation in the home of Patient 9 at 1:30 PM on 1/28/26, the surveyor reviewed the documents provided to the patient on admission. The State Hotline number was not provided. There was an empty box for “State home health hotline number” but no phone number was provided. During an observation in the home of Patient 11 at 2:30 PM on 1/28/26, the surveyor reviewed the documents provided to the patient on admission. The State Hotline number was not provided. There was an empty box for “State home health hotline number” but no phone number was provided. During an observation in the home of Patient 7 at 11:00 AM on 1/29/26, the surveyor reviewed the documents provided to the patient on admission. The State Hotline number was not provided. There was an empty box for “State home health hotline number” but no phone number was provided. During an observation in the home of Patient 10 at 12:30 PM on 1/29/26, the surveyor reviewed the documents provided to the patient on admission. The State Hotline number was not provided. There was an empty box for “State home health hotline number” but no phone number was provided. During an observation in the home of Patient 8 at 1:30 PM on 1/29/26 , the surveyor reviewed the documents provided to the patient on admission. The State Hotline number was not provided. There was an empty box for “State home health hotline number” but no phone number was provided. In an interview with the Administrator at 12:15 PM on 1/30/26, the Surveyor re-reviewed the patient admission packet with the Administrator. The Surveyor showed her where state hotline box was blank and asked what the process is for providing patient’s that number. The Administrator stated they were supposed to provide the number to patients, and she said that usually the admitting clinician will write the number in. The Surveyor asked if the number was anywhere else in the packet. Administrator looked through the packet in the presence of the surveyor and was unable to find the State Hotline number labeled and provided for patients. The Surveyor asked if it was important for patients to have easy access to this information. The Administrator stated it was “absolutely important” that patients have access to the number and know how to file a complaint against the agency if they need to. The Surveyor stated that in 7 out of 7 patient admission packets reviewed while out on survey, none had the number written in the box. The Administrator stated that that is something the clinicians provided, and stated that the nurses likely just got busy during an admission and forgot to write it. In a phone interview with RN C at 12:30 PM on 1/30/26, she stated that she completed admission assessments for new patients. She stated that she went over the admission packets in detail with new patients and went over all the numbers written in the packet to call. The Surveyor mentioned that there was a blank box next to the State hotline number and asked if she had ever written a number in there or received education that that was an expectation. RN C stated that she had not. In a phone interview with RN A at 9:45 AM on 2/2/25, RN A, another nurse who performs patient admission visits, confirmed that she has never been directed to write in the state Hotline number in the blank box in the Admission Packet. RN A stated that she typically directed patients to call her or the PT if they have complaints about the LVNs or PTAs, and that they also included the Administrator’s number in the Admission Packet and informed patients they can also call that number if the complaint needs to be elevated. The Surveyor asked if she informed patients that they could call the HHSC Hotline. She stated that she herself has used the Hotline before but did not typically discuss it with patients. Review of the agency’s policy titled, “Patient Complaint Management,” last reviewed 04/2022, revealed a document that read in part, “The “My Home Health Resources Booklet” (in Home Health Start of Care Kits) states patients are: advised as required by the patient’s bill of rights of the names and contact information for their local Home Health agency’s Administrator [“Branch Director”] and Clinical Manager to notify regarding a complaint or grievance without fear of reprisal or unreasonable interruption of care. notified in writing [“Section 1: My Patient Resources” of the Booklet] and verbally of the purpose and contact information for their respective state’s home health hotline and, as applicable, available patient advocacy resources as required by state regulations.””