Pinnacle Home Health Care Services

“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 to the CMS system, within 30 days of completing the assessment of the patient for 47 of 452 (10.40%) assessments processed for the time reviewed of 1/1/2025 to 12/31/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare, failing to be reported to CMS in the required time frame. Findings: The HHA Error Summary Report, retrieved from the iQIES website for the time of 1/1/2025 to 12/31/2025 was reviewed. Review of the HHA Error Summary Report in IQIES for the time-period 1/1/2025 to 12/31/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with the error was 10 assessments and the percentage of assessments with this error was 10.40% of the total of 452 assessments completed by the Agency. An interview was conducted with the Admin on 5/28/2026 at 1:30 PM. The HHA Error Summary Report was reviewed with the Administrator. The Administrator stated that they use a QA company that is responsible for keeping track of OASIS submission. Ultimately the Admin acknowledged the responsibility of the late submission. During a record review of an agency policy titled, “Timelines,” last reviewed 12/01/14, read in part… “ all completed and encoded OASIS data will be transmitted via electronic communication software… from the Agency… within 30 days of the M0090 date…””

“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 allegations of theft of money and exploitation by an agency employee to HHSC within 24 hours for 1 of 9 Patients reviewed (Pt 1), in that: The agency had cause to believe that PROV A exploited money from Pt #1. This failure placed patients at risk of further abuse, neglect, or exploitation by agency employees. Findings included: Review of agency complaint log for 2023, 2024, 2025, and 2026 revealed an agency form titled “Patient Complaint Form” which had an entry dated 4/5/2025 with Pt #1’s name and Prov A listed as employee involved. Employee receiving complaint was listed as Admin and investigation completed by SUP A. Review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self- reported incidents on home health agencies for the State of Texas) on 5/27/2026, revealed no self-reported incidents regarding Pt #1 were received by the date of entrance survey on 5/28/2026. Further review of this complaint revealed the following information: “Description of complaint: [Patient name] was discharged from the hospital on April 15th Saturday. [SUP A name] received call from [Patient name] about [Prov A name] stealing money. [Prov A name] fled the apartment and police were called”. The complaint form displayed three separate signature lines at the bottom of the form that read “Investigated by”, “Employee signature”, and “Supervisor signature”. Investigated by signature line contained the name of SUP A. “Employee signature” line contained “verbal” under employee signature and “Supervisor signature” was blank except for a date of April 5th, 2025. Record review did not reveal documentation that the agency reported these allegations to HHSC within 24 hours of being made aware of the allegations. Further record review revealed no documented evidence of a police report on the complaint form. Record review of PROV A’s employee file revealed a hire date of 12/26/2024 with job titled as personal attendant. PROV A’s employee file revealed an initial NAR/EMR check on 12/26/2024, a background check on 12/26/2024 and training for abuse, neglect, and exploitation completed upon hire. Record review further revealed that PROV A was terminated on 4/15/2025. Three attempts were made to contact PROV A on 5/28/2026 and 6/3/2026, with no return call from PROV A. In an interview with the Admin on 5/29/2026 at approximately 12:00 PM, the Admin was presented the above findings. The Admin stated that SUP A was responsible for all of the investigations of complaints. The Admin also stated that he didn’t know all of the details of the complaint. When asked why the incident was not called in to HHSC, the Admin stated that he preferred to handle situations quickly on their end, without the assistance of the State. The Admin admitted responsibility for what happens within the agency for the safety of the agency’s patients. An interview with SUP A was conducted on 6/3/2026 at approximately 10:30 AM. The Surveyor asked SUP A what she recalled about the incident. SUP A stated that the complainant claimed PROV A took from him. Surveyor asked SUP A if she obtained a copy of the police report noted in the complaint form. SUP A stated that she didn’t believe a report was filed and that Pt #1 only said this to scare PROV A. When Surveyor asked why this complaint was not called into the State, SUP A stated that they handle their investigations internally. Surveyor asked SUP A who was responsible for reporting incidents to HHSC and SUP A stated the Admin is responsible for reporting complaints to the state. SUP A was able to verbalize the ANE reporting policy for the agency. SUP A also reiterated that the Admin is responsible for reporting to the State. Record review of agency policy titled “Abuse, Neglect, and Exploitation” revised 09/01/13 read in part… “agency management… report if cause to believe abuse, neglect, or exploitation of the patient has occurred by a staff member, immediately, meaning within 24 hours to: Texas Department of Family and Protective Services…””