Accentcare Home Health of Temple

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on record review and interview the agency failed to report an alleged act of neglect of a patient by an agency employee within 24 hours to HHSC as required by state law for 1 of 3 Patients (Patient 2) whose records were reviewed in that: The agency received a complaint of alleged neglect on 10/30/25 but did not report it to HHSC. This failure placed Patients at risk of continued neglect by agency staff. This failure could potentially affect all Patients who received care from HHA 1. Findings included: Review of the document titled, “Complaint Report,” dated 10/30/25, revealed the following complaint was received on 10/30/25: “Patient secondary contact stated via text ‘[Patient 2] came down with severe infection. I don’t know if it is your job or someone else who was to keep her wounds clear, but they got infected and infection went septic. She is now at [SN Facility 1]. She almost passed away. She will not be going back home. I am not happy with the care she received. She never should have been sent home with these wounds. The nurse was scheduled to come on Monday. Her wound opened up Friday night and by Sunday night we called 911 and they worked on her for an hour in the ambulance before they could transport. [The neighbor] said she looked like she was going to pass. If you people can’t provide care on a weekend then she should have never been sent home to begin with.’” Review of HHA’s TULIP (a database used by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies) profile revealed no self-report intake was created for this incident. In interview with the Administrator on 3/11/26 at 3:05 PM, she stated that is the agency’s policy to report all possible allegations of Abuse, Neglect, or Exploitation to the State within 24 hours of when “it comes to light”. She stated that if “it’s is a gray area or a question at all than we escalate it to our leadership and will investigate more and self-report if necessary.” The Surveyor showed the Administrator the above complaint and asked why it was not reported to the state for possible neglect. She stated she did not know. She stated the Territory Manager would have looked at it and decided if it needed to be escalated. In an interview with the Territory Manager at 3:15 PM on 3/11/26, she stated that she did escalate the complaint and they did a “timeline of events” for the incident, which then goes to the corporate upper management. She stated that she did not receive further direction from upper management to report it to HHSC so she did not self-report it. She stated that when she spoke with FM 2, the focus of his complaint was that Patient 2 “never should have been discharged” from the rehab facility she had been in prior to starting care with the agency if she was “so at risk” for infection. Territory Manager stated that because that was his focus of the call, she was not really thinking this was an allegation of neglect. The Surveyor pointed out that the original text message from FM 2 (above), however, was aimed at the agency not providing proper wound care which resulted in a deterioration of condition and the patient being readmitted to the hospital and would be considered an allegation of neglect Review of the agency’s policy titled, “Incident and Adverse Event Reporting,” last revised 6/13/24, revealed the following statement: “Incidents are reported to state authorities, if required, according to state regulations.” Further review of the document revealed the statement: “If an agency has cause to believe that a patient served by the agency has been abused, neglected, or exploited by an agency employee, the agency must report the information immediately, meaning within 24 hours, to: (1) TX HHSC at phone # 1-800-458-9858; Alternate reporting mechanisms via Texas Unified Licensure Information Portal (Tulip), via email at [CII email address].””

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to enforce their written policy regarding coordination of services to ensure the effective coordination of patient services in 1 out of 3 patients (Patient 2) whose records were reviewed in that: The agency failed to obtain orders for wound care and communicate a change in condition to the physician and clinical team when Patient 2 developed bilateral leg wounds. This failure resulted in the patient’s wounds worsening which contributed to her hospitalization on 10/20/25. Findings included: Review of the HHA 1’s policies revealed a document titled, “Care Planning and Coordination,” last revised on 6/10/25, which read in part, “The case manager or primary clinician is responsible for facilitating communication about patient status changes, including a change of orders among all assigned disciplines and with the patient, physician , Patient Care Manager, and facility application. Agency personnel involved in patient care will communicate changes and care coordination activities to the case manager or designated Patient Care Manager (PCM) in a timely manner via telephone, one on one meetings, case conferences, and home visits.” Further review of the document revealed the following: “Documentation of care coordination activities, including communication with members of the health care team […] will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will consist of :the date and time of the communication, individuals involved with the communication, information discussed, and the communication outcome…” Review of the document titled, “Consumer Rights and Services Complaint Investigation Worksheet” dated 12/5/25, revealed a complaint was filed to CII which read, in part, “Home wound care nurse came and overlooked infection. She wrapped the wound without following up on whether an infection was setting in. This could have been avoided if the homecare nurse would have followed up on infection. Instead the nurse wrapped the wound and left her confined in the wheelchair all weekend. She couldn’t eat, drink, soiled her pants and a very severe bed sore developed on her bottom. She continues her recover now some six weeks after the incident.” Review of the document titled, “Home Health Certification and Plan of Care,” dated for the period of 9/19/25 - 11/17/25, revealed Patient 2’s Plan of Care. Patient 2’s relevant diagnoses were listed as Chronic Congestive Heart Failure (chronic, progressive condition where the heart cannot pump enough blood to meet the body’s needs, leading to fluid buildup in the lungs and body) , Type 2 Diabetes Mellitus (a chronic condition causing high blood sugar due to cells not using insulin properly), Hypertension (high blood pressure), Chronic Kidney Disease (a chronic, progressive loss of kidney function which can lead to fluid buildup), Intervertebral Disc Displacement (displacement of a disc in the back causing pain), spinal stenosis (narrowing of the spinal canal causing pain/weakness), spondylosis (age related spinal degeneration), chronic pain, hyperlipidemia (high cholesterol), long term (current) use of opiate analgesics (strong painkillers that can cause grogginess and increase fall risk), and history of falling. The Plan of Care has an ordered frequency of nursing visits as “1wk9” or once a week for 9 weeks. The Plan of Care also has an ordered frequency of physical therapy effective 9/21/25 as twice a week for 1 week, once a week for 3 weeks, and then once every 2 weeks for 4 weeks. The following orders were included on the plan of care: “Skilled nurse to observe and assess integumentary status to identify untoward changes and intervene to minimize complications” ; “Pt/CG to weigh daily and SN to perform/record weights q visit. If pt unable to safely weigh SN to measure calf, ankle or abdominal girth. Notify provider of 2 cm increase from baseline at each visit or weights outside of established parameters.” The following parameters were provided: “Licensed professional to report vital signs falling outside the following established parameters. Temperature 100.3 Pulse 11,0 respirations (breaths) 26 systolic BP160, diastolic BP100, weight>226, pain>7, o2 saturation (measure of oxygen in blood) <92.” Review of the document titled, “Visit Note Report,” dated 9/19/25, revealed a nursing note by RN A for “RN OASIS Admission” for Patient 2. The note read, in part, under the heading “Integumentary” (Skin), “No problems identified.” Further under this heading there was a statement which read, “Patient has no pressure ulcers/injuries or no stageable pressure ulcer/injuries.” Review of the document titled, “Visit Note Report,” dated 9/22/25, revealed a nursing note by LVN A from Patient 2’s second nursing visit. The note read, in part, under the heading “Integumentary” (Skin), “No problems identified.” Review of the document titled, “Visit Note Report,” dated 9/29/25, revealed a nursing note by LVN B from Patient 2’s third nursing visit. The note read, in part, under the heading “Integumentary” (Skin): INTEGUMENTARY ASSESSMENT FINDINGS: (MARK ALL THAT APPLY) MOIST; OTHER (SPECIFY) - OTHER INTEGUMENTARY ISSUE(S): BLE OOZING MODERATE AMOUNT OF CLEAR/YELLOWISH FLUID.” Under the “Narrative” heading of the note, the following was written: “Patient reports 7/10 pain to BLE. +3 non-pitting (does not leave indentation when pressed) edema (swelling) noted to BLE. BLE has a moderate amount of clear/yellowish drainage. MD notified for possible wound care evaluation and to report weight out of parameters. Patient has an appointment with [MD A] this Thursday 10/2. T/I (teaching/instruction) - instructed patient/caregiver on risk factors.” Although physician notification was documented, Clinic 1 did not have documentation of receiving a call from any HHA 1 nurse that day (see interview below). Furthermore, no wound care orders were received from MD A until 10/27/26, by which time the patient was already hospitalized. Review of the document titled, “Visit Note Report,” dated 10/7/25, revealed a nursing note by LVN C from Patient 2’s fourth nursing visit. The note read, in part, under the heading “Integumentary” (Skin), “No problems identified.” Further review of the document revealed a narrative that read: “BLE ARE EDEMATOUS, PATIENT STATES THAT HER LEGS DRAIN SOMETIMES, SN NOTED NO DRAINAGE AT TIME OF VISIT.” Review of the document titled, “Visit Note Report,” dated 10/17/25, revealed a nursing note by LVN D from Patient 2’s fifth nursing visit. The note read, in part, under the heading “Integumentary” (Skin), “No problems identified.” However, the narrative reported the following: “Patient came to door in wheelchair, BLE scaly, and weeping. Floor/whatever feet touch is wet. Patient states WCC called about her coming in for an appointment but she told them she was unable. Patient states WCC is supposed to be Sending orders over to agency […] elevate BLE on stool. Place towel/pad under feet due to floor leakage… Care coordination: will give report to [Case Manager] and [PCM].” This note was also the first note to include wound documentation. A “Wound Assessment” for wounds on both legs was opened in the note, with the Wound location labeled as mid pretibial, right, weeping areas - onset date 10/17/25 and pretibial, mid, left, weeping areas, onset date 10/17/25. Both wounds were documented on as 36-50% necrotic tissue slough. For both wounds, under the column “Signs and Symptoms of infection?” the nurse documented “NO”. For both wounds, under the column “Exudate (drainage) type”, the nurse documents “serous” and under the column “exudate amount” the nurse documented “large”. For both wounds, under the column, “Wound Care Provided,” the nurse documented “Using clean technique, cleansed with normal saline and gauze, patted dry with gauze, applied dry gauze pads and secured with gauze wrap and tape. Tolerated well.” No communication with the physician to notify them of Patient 2’s change in condition was noted. Review of a photograph that LVN D took on 10/17/25 during the visit with Patient 2 revealed images of Patient 2’s leg wounds. Both legs were swollen and scaly, with open wounds from the knee to the ankle, yellowish drainage, and pink and red areas throughout. Review of the document titled, “Order Number 13049490” dated 10/17/25 and signed by MD A on 10/27/25, revealed the following order: “Agency wound care protocol: Using clean technique: Cleansed with normal saline and gauze, patted dry with gauze. Applied dry gauze pads and secured with gauze wrap and tape.” The patient’s electronic health record was reviewed for any other documentation of care coordination or physician follow up. No other communications were recorded in the “Coordination Notes”. In a phone interview with FM 2 on 3/10/26 at 2:24 PM, he stated that Patient 2 lived alone but he helped manage her care. He stated that on 10/17/25 a nurse came and “just left her there alone with infected wounds”. He alleged that the leg wounds became infected and left Patient 2 weakened to the point that she could not get out of her wheelchair. Per FM 2, since Patient 2 lived alone, she was stuck in her wheelchair for over 2 days when a neighbor found her and called EMS . She was hospitalized and has been back and forth from hospitals and skilled nursing facilities ever since. She had developed a new pressure ulcer on her buttock. He stated he was not sure if MD A was aware of this incident. In an interview with LVN D at 2:46 PM on 3/10/26, she stated she remembered the wound, and that the patient shoes were wet from the drainage of the wound. She stated she remembered calling about them but could not remember if she called the doctor or the PCM (Patient Care Manager). She stated she thought the patient was supposed to go to wound care clinic. She stated that she remembered cleaning the wound with normal saline and wrapping them with gauze. She stated that when she was there, the patient was alert and able to get around on her own. She stated she did not know if the patient had caregiving services. The Surveyor asked her what the agency policy was on documenting communication with the physician. She stated she would have typically put it in her note if she called the physician. In a phone interview with LVN C at 4:10 PM on 3/10/26, she stated she remembered seeing Patient 2. She stated she remembers being on the floor and removing Ace bandages from the patient’s legs and cleaning her legs. She stated there was no drainage at the time. She stated Patient 2’s legs were not yellow and did not look infected at the time. She said they were dry but swollen and a little scaly. She stated at this time the patient was able to get out of her wheelchair and walked the length of the room and was able to take care of herself. LVN B was called twice but was unable to be reached for interview - once on 3/11/26 at 1L33 PM and once on 3/12/26 at 3:02 PM. Voicemails were left. Patient 2 was in the ICU at the time of survey and unavailable for interview. In an interview with PCM at 10:55 AM on 3/11/26 she stated her role is to supervise the case managers who supervise the clinicians. She stated that when an issue arises, the clinicians are supposed to notify the case manager and herself (PCM) so she can try to coordinate and follow up to make sure the patient is taken care of. She stated that they need orders to do any kind of wound care. She stated that they would not have been doing ace wraps without orders, and she said that LVN C must have been mistaken about that. She stated they have a “nursing protocol” when a new wound is found, that included cleaning the wound with NS and wrapping in gauze, but then the nurse must notify the physician and obtain wound care orders to continue caring for the wound. PCM did not remember a conversation about Patient 2 with LVN D or any of the other LVNs who cared for Patient 2. The surveyor showed her the picture of the wounds that LVN D took on 10/17/25. She stated that she would have called the doctor if she had seen that picture, but she stated she likely did not see the picture until it was uploaded in the chart a couple days later. In an interview with Case Manager at 11:16 AM on 3/11/26, she stated that she did not remember Patient 2 specifically or being notified about her wounds. The Surveyor showed her where LVN D had documented that she would give report to her (Case Manager) and PCM. Case Manager stated that LVN D is usually good about calling with concerns, and if she was unable to get ahold of them, she usually would send an email. Surveyor asked her to check her emails, but Case Manager could not find an email about this incident. The Surveyor showed Case Manager the picture of the wounds LVD D took on 10/17/25. The Surveyor asked what the agency’s policy was on coordination of care and what LVN D would be expected to do if she assessed wounds like these on a patient. Case Manager said the expectation would be to elevate it to the Case Manager and the PCM. She stated it was the nurse’s responsibility to notify the physician if the wounds were new or had significantly worsened. In a phone interview with RN A at 11:27 AM on 3/11/26, he stated that he did not specifically remember Patient 2, and that he usually just does Start of Care visits, so he only sees the patients one time. In an interview with the Administrator at 1:44 PM on 3/11/26, she looked up the case manager for Patient 2 and confirmed it was Case Manager. In another interview with Case Manager at 2:38 PM on 3/11/26, the Surveyor showed her where LVN B documented that she notified the MD of the new wounds. The Surveyor asked Case Manager why no wound care orders were ever obtained if the wound was first noticed on 9/29/25. Case Manager stated that it was the responsibility of the nurse to get the wound care orders. The Surveyor pointed out that this patient was seen by a different nurse every week and asked who was responsible for following up if wound care orders were never received. The Surveyor asked if it was part of her responsibility as the case manager to follow up on these things, particularly when the patient is seen by different clinicians every week. Case Manager stated that she would not have even known about the wound unless the nurses called her about it. She stated she did not remember receiving any calls or notifications from the nurses about this wound. The Surveyor asked why it was important that the clinical team works together to coordinate care and work together to follow up on issues related to patient care. Case Manager stated it was important to ensure they get orders so they can effectively treat the wound and get it to heal properly. In an interview with the Administrator at 3:05 PM on 3/10/26, the surveyor asked her if a nurse notified an MD about a change in a patient’s condition, but orders were never received, whose responsibility would it be to follow up on that. The Administrator stated that it would be the nurse who called the MD and the next assessing nurse to ensure they had orders to care for the wound. She stated it was “basically the whole team’s responsibility to make sure the patients receive the care they need”. The Surveyor asked her what the policy was on coordinating care. She stated that all members of the team should be communicating with each other and their case manager and PCMs to ensure a patient receives proper care if new needs arise. The Surveyor asked her why it was important to ensure the patient care is being coordinated among clinicians at the agency and the patient’s physician. She stated that it affects patient care. She stated, “our patients are at risk and are receiving services for a reason. They have a need and it is our job to catch a problem before it becomes a big problem.” In an interview with the Clinic RN B, who worked for MD A at Clinic 1, at 4:17 PM on 3/12/26, the Surveyor asked her if the clinic received any calls or notification from any of the nurses at HHA 1. Clinic RN B checked the patient’s records and stated that no calls were documented. The Surveyor had her specifically check on 9/29/25, when LVN B said that she called, and 10/17/25, when LVN D may have called. Clinic RN B confirmed that they always document calls from home health nurses and stated she had nothing documented for those days.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide all services ordered by the physician in the plan of care in 1 out 3 patients whose records were reviewed (Patient 2). In 1 out of 5 of Patient 2’s nursing visits, the nurses did not document a weight or calf measurement as ordered in the Plan of Care, which is vital for monitoring edema (swelling) in a CHF patient. This failure resulted in a lack of monitoring of Patient 2’s edema, particularly in her legs, which contributed to the deterioration of her leg wounds and led to a change in condition. Findings included: Review of the document titled, “Home Health Certification and Plan of Care,” dated for the period of 9/19/25 - 11/17/25, revealed Patient 2’s Plan of Care. Patient 2’s relevant diagnoses were listed as Chronic Congestive Heart Failure (chronic, progressive condition where the heart cannot pump enough blood to meet the body’s needs, leading to fluid buildup in the lungs and body) , Type 2 Diabetes Mellitus (a chronic condition causing high blood sugar due to cells not using insulin properly), Hypertension (high blood pressure), Chronic Kidney Disease (a chronic, progressive loss of kidney function which can lead to fluid buildup), Intervertebral Disc Displacement (displacement of a disc in the back causing pain), spinal stenosis (narrowing of the spinal canal causing pain/weakness), spondylosis (age related spinal degeneration), chronic pain, hyperlipidemia (high cholesterol), long term (current) use of opiate analgesics (strong painkillers that can cause grogginess and increase fall risk), and history of falling. The Plan of Care has an ordered frequency of nursing visits as “1wk9” or once a week for 9 weeks. The Plan of Care also has an ordered frequency of physical therapy effective 9/21/25 as twice a week for 1 week, once a week for 3 weeks, and then once every 2 weeks for 4 weeks. The following orders were included on the plan of care: “Skilled nurse to observe and assess integumentary status to identify untoward changes and intervene to minimize complications” ; “Pt/CG to weigh daily and SN to perform/record weights q visit. If pt unable to safely weigh SN to measure calf, ankle or abdominal girth. Notify provider of 2 cm increase from baseline at each visit or weights outside of established parameters.” The following parameters were provided: “Licensed professional to report vital signs falling outside the following established parameters. Temperature 100.3 Pulse 11,0 respirations (breaths) 26 systolic BP160, diastolic BP100, weight>226, pain>7, o2 saturation (measure of oxygen in blood) <92.” Review of the document titled, “Visit Note Report,” dated 9/22/25, revealed a nursing note by LVN A from Patient 2’s second nursing visit. No weight or calf or abdominal measurement was included in this note. LVN A was called at 2:02 PM on 3/11/26 but the line did not allow the surveyor to leave a voicemail. This nurse no longer worked for the agency and the agency was unable to provide a different contact number. LVN B was called twice but was unable to be reached for interview - once on 3/11/26 at 1:33 PM and once on 3/12/26 at 3:02 PM. Voicemails were left. Patient 2 was in the ICU at the time of survey and unavailable for interview. In an interview with the Administrator at 3:05 PM on 3/10/26, the surveyor asked what the agency’s procedure was for following orders in the plan of care. The Administrator stated that all clinicians were expected to follow all orders in the Patient’s Plan of Care. She stated if they were unable to do that, or if the patient’s condition has changed and requires new orders, then they should call the physician to get new orders and notify their PCM, who may decide to send out an RN to assess the Patient. The Surveyor asked why it was important to notify the physician if orders in the plan of care are not followed or need to be updated? She stated the physician signed the Plan of Care, and they need to be aware of the patient’s condition and what they need and may need to see them in the office if the plan of care is no longer meeting their needs.”