Heritage Home Health of East Texas

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a registered nurse conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician order start of care date for 1 of 4 patient records reviewed. (Client #1) The agency did not provide an initial assessment of Client #1 within 48 hours of her discharge from the nursing facility. This failure could have resulted in a delay in addressing client needs and required services in a timely manner and could cause decline in client health status. Findings included: Record review of a policy titled Timelines dated 07/01/2025 1. All agency staff, physicians and/or non-physician practitioners and physician office staff, as appropriate, will be oriented to the following parameters: A. The evaluation visit for admission to agency is conducted within 48 hours of referral, or within 48 hours of the patient/clients return to home, or on the physician and /or non-physician practitioner start of care date. Record review of a spreadsheet titled Referrals indicated the agency received a referral from the nursing facility for Patient#1 on 12/3/2025. Record review of a spreadsheet titled agency admissions for December 2025 did not indicate Patient#1 was admitted to services. Record review of a spreadsheet titled Non-admissions indicated Patient#1 was a non-admission. Record review of an email dated 12/5/2025 indicated Intake Coordinator C said Patient#1 had picked the agency for home health services. Record review of an email dated 12/5/2025 indicated Intake Coordinator C received a message from Liaison A regarding Patient#1’s discharge from the nursing facility being on hold. Record review of an email dated 12/12/2025 at 2:11 PM indicated Intake Coordinator C was notified by Liaison A, Patient#1 discharged from the nursing facility on Wednesday 12/10/2025 and he did not see the message until this morning. Intake Coordinator C questioned if she needed to wait until the office visit note from Patient #1s doctors visit yesterday. Record review of an email dated 12/15/2025 at 1:12 P.M., from the lead admission coordinator indicated she was sending Patient#1 referral for start of care. Record review of an email dated 12/15/2025 at 3:26 p.m. from the lead admissions coordinator indicated she had spoken with Patient #1’s daughter, she was good for Wednesday start of care if the patient did not end up back in the hospital due to the nursing facility discharged her with a urinary tract infection. Record review of an email dated 12/16/2025 at 3:50 p.m. from the lead admissions coordinator indicated Patient#1’s daughter called and said patient was picked up by another home health agency and the agency would be non-admitting. The email indicated Patient#1’s doctor sent to another agency because the agency did not admit within 48 hours. During an interview on 1/21/2026 at 11:49 a.m. Liaison A said he had not officially started working for the agency when the referral for Patient #1 was received. Liaison A said originally, he was given this referral by nursing facility B when he was still employed by another home health agency. Liaison A said he notified the case worker at nursing facility B that he had resigned from his current position and would be starting at this agency. He said he told the social worker she could fax the referral to his current agency or if the patient requested the referral could be sent to the agency he would be employed by on 12/15/2025. He said the social worker spoke with Patient #1 and she requested to go with this agency. He said Patient#1’s discharge from nursing facility B was delayed. He said the week of 12/9/2025 he was home sick and missed the text message from the social worker at nursing facility B that notified him the patient was being discharged the next day on 12/10/2025. Liaison A said he did not see this text message until 12/12/2025 and he contacted this agency to notify them of the discharge from nursing facility B so that an admission visit could be scheduled. Liaison A said a standard admission would take place normally within 24 hours of discharge from the nursing facility. Liaison A said he took accountability for missing the text message notification of discharge. Liaison A said Patient#1 was ultimately a non-admission. During an interview on 1/21/2026 at 12:17 p.m., the alternate administrator said the agency did receive the referral for Patient#1 from nursing facility B on approximately 12/5/2025 but the referral did not indicate a discharge date and the agency did not receive any communication regarding Patient#1’s discharge from nursing facility A or the liaison who had not officially started with the agency until around 12/12/2025. During an interview on 1/21/2026 at 12:30 p.m. the lead admissions coordinator said when a referral was received from a nursing facility without a discharge date, they should follow up with the nursing facility to ensure the patient did not get discharged without their knowledge. The lead admissions coordinator said she was not aware of the reasons behind the intake coordinator not reaching out to the facility after the referral of Patient #1. The lead admissions coordinator said clients should be admitted within 48 hours of discharge from the facility. During an interview on 1/21/2026 at 12:40 p.m., intake coordinator C said when she received a referral from a nursing facility, she sent an email to all intake staff for benefit check, ensured patient was not a current or previous client, and if the intake came directly from a nursing facility without a discharge date, she stayed in contact with the facility at least every other day to monitor for discharge. Intake Coordinator C said she was familiar with the referral for Patient #1. Intake Coordinator C said she had been communicating with Liaison A regarding Patient#1’s referral even though he had not officially started at the agency. Intake Coordinator C said she found out from Liaison A on 12/12/2025 that Patient#1 had been discharged from the nursing facility on 12/10/2025. She said after being notified she had been discharged home several questions came up regarding Patient #1 such as did the agency service the area where the patient was and was the patient home health appropriate. She said she was unsure why there was a gap in time between 12/12/2025 and 12/15/2025 when the agency called to schedule the admission for 12/17/2025. During an interview on 1/21/2025 at 12:52 p.m., the alternate administrator said there was admittedly a huge gap in time between 12/12/2025 when they were told Patient#1 had been discharged from the agency and 12/15/2025 when Patient#1 was contacted to schedule an admission assessment. The alternate administrator said if he had been aware of this delay he would have sent someone from the agency to do the admission assessment much sooner. The alternate administrator said clients should be admitted to services within 48 hours after discharge from the nursing facility. The alternate administrator said it was important for admissions to be done timely because many times the patient was being discharged from a nursing facility or hospital and was in the middle of an acute (sudden onset) situation and as to not delay care. The alternate administrator said generally it was the liaisons responsibility to communicate with the nursing facilities to get a discharge date but it was intakes responsibility to follow up with the referral source in the absence of the liaison. During an interview on 1/21/2026 at 1:52 p.m. the DON said the only part she played in intake/referrals was the clinical review to see if the patient referred was appropriate and if the agency had appropriate staffing to care for the client. The DON said clients should be admitted to home health services within 48 hours of discharge from the nursing facility unless the patientor client’s family requested otherwise. The DON said this timeline was important to provide adequate and quality of care. The DON said she had not been made aware of Patient#1’s referral or non-admission to the agency.”