Triple O Health Services Inc.

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interviews, the agency’s governing body (or designated persons so functioning) failed to be responsible for the overall management of the agency’s operations in that: The Administrator, a governing body representative, did not ensure the agency was actively engaged in planning for or providing skilled services for the agency. The agency had not provided skilled services since the last survey in 2022. This failure placed the agency at risk of not having the staff and other services in place to provide care for skilled patients if needed and prevented the surveyor from determining the agency’s compliance with Federal provider requirements. Record review during pre-survey preparation for the agency on 08/04/2025, the surveyor did not find reports for Potentially Avoidable Event, Agency Patient- Related Characteristics Tally, or Potentially Avoidable Event Patient Listing for the last 12 months reviewed. The HHA Error Report Summary for the HHA for period 08/04/2024-08/04/2025, dated 08/04/25 read, “No Data Returned for Selected Criteria.” Record review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on home health and hospice agencies for the State of Texas), showed the following: 1. The agency maintained a current license to provide Licensed and Certified Home Health Services; Licensed Home Health Services and Personal Assistance Services for licensure period of 05/31/2024 to 05/31/2027. 2. Listed Alternate Administrator as the owner at 100.00 % since 02/26/2006. Reviewed agency’s employee roster for skilled services. The roster had only the DON and ADON listed as skilled nurses for the agency. Record review agency document titled, “Professional Advisory Committee.” The document was dated 12/28/2024. The document was signed by the Adm as the governing body representative and the AA as the Administrative staff representative. The document did not include on the agency planned to get skilled patient admissions for L&C category listed on license. Reviewed agency’s annual evaluation reports for years 2022, 2023, and 2024. The annual evaluation reports did not address how the agency planned to get skilled patient admissions for L&C category listed on license. During entrance conference on 08/05/2025 at 10:05 a.m., the Adm stated the agency only had PAS patients. When asked if the agency planned to surrender or keep L&C category on its license, the Adm said he would keep the category and wait to see if the agency received referrals from doctor offices. During continued interview on 08/05/25 with the Adm at 11:30 a.m., when the surveyor asked about marketing efforts the Adm said the agency did not market to get referrals because it was against the law. When Adm was asked why he thought marketing was against the law the Adm said that was what the state said, and other agency owners told the Adm that they got in trouble for marketing and had to pay fines. The Adm said he did not want to get in trouble. When asked how he received referrals the Adm said he waited on the doctor offices to send him referrals for skilled services. During continued interview on 08/07/25 with the Adm at 10:10 a.m. the Adm said the agency last skilled patient was during the last survey of the agency in 2022. The Adm said the AA was the owner of the agency and that the DON and ADON both still worked for the agency but part- time since the agency had no skilled patients. The Adm said he was responsible for getting referrals for the agency. When asked how no skilled services and staff for skilled services could affect patients, the Adm said the agency had two nurses and could get other staff on contract if needed. During interview conducted on 08/07/25 with AA at 10:56 a.m. the AA said she was aware the agency had no skilled patients since last survey. When asked about surrendering the L&C category from their license for the agency since the agency had not admitted skilled patients since 2022, the AA said she did not want to surrender the L&C category on the license. When the AA was asked about marketing efforts for skilled patients for agency the AA did not answer. The AA just smiled at surveyor and then looked at Adm. During interview conducted on 08/07/25 with DON at 11:33 a.m. the DON said she had been in the position for the agency since 2018. The surveyor asked how the DON attempted to get skilled clients for the agency. The DON said she did nothing, just continued to wait for referrals from doctor offices. Review of the HHA’s policy titled, “Governing Body,” dated 2003, read in part, “Policy: 3. It is the policy of this agency to adhere to the State, Federal, regulations for Home Health Care regarding Governing Body meetings… Governing Body Duties: 1. To arrange for professional advice as required. 2. To appoint a qualified Administrator. 3. To adopt and periodically review written by laws or an acceptable equivalent and oversee the management and fiscal affairs of the agency. 4. To review the annual budget. 5. Assumes the full legal authority and responsibility for the operation of the agency.””