Complete Homecare Services Inc.

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to directly furnish skilled nursing or other therapeutic services (physical therapy, speech‐language pathology, or occupational therapy; medical social services; or home health aide services) to at least one patient during 3 of 3 years reviewed. (2023, 2024, 2025) The agency did not have any L&C (skilled) patients in 2023, 2024, or 2025. This failure placed patients at risk of inadequate care when HHSC is unable to survey the agency’s compliance with federal licensing standards for skilled nursing. Record review of TULIP (a database utilized by the state to maintain licensing, and demographic information, on Home Health and Hospice agencies for the State of Texas) on 4/9/26 indicated a renewal license application, APP- 0062603299, dated 04/04/23 for the licensure period 5/31/23 - 5/31/26. The application indicated the category for services were L&C, LHH, and PAS, and indicated the census for PAS was 130. The census for L&C and LHH services was left blank. Record review of TULIP on 4/9/26 indicated a license renewal application, APP- 0062659430, dated 03/27/26 for the licensure period 05/31/26 - 05/31/29. The application indicated the category for services were L&C, LHH, and PAS, and indicated the census for PAS was 80. The census for L&C and LHH services was 0. Record review of the Home and Community Support Services Program Unduplicated Census form completed by the agency on 4/13/26 indicated the current active census for the Parent and Branch locations was: Parent location L&C-0, LHH-0, PAS-80; Branch location L&C-0, LHH-0, PAS-117. Record review of the Current Active Patient Report dated 4/13/26 gave no indication that the agency had any current L&C (skilled) patients on service. Record review of the Discharged Patient List dated 4/12/25- 4/12/26 from the parent and branch locations gave no indication that the agency had any L&C (skilled) patients discharged from service during the reported timeframe. Record review of the Inactive [Discharged] Patient List dated 1/1/23- 12/31/23 from the parent and branch locations gave no indication that the agency had any L&C (skilled) patients discharged from service during the reported timeframe. Record review of the Inactive [Discharged] Patient List dated 1/1/24- 12/31/24 from the parent and branch locations gave no indication that the agency had any L&C (skilled) patients discharged from service during the reported timeframe. Record review of the Inactive [Discharged] Patient List dated 1/1/25- 12/31/25 from the parent and branch locations gave no indication that the agency had any L&C (skilled) patients discharged from service during the reported timeframe. During an interview on 4/13/26 at 9:30 am the Alternate Administrator/ Supervising Nurse said the agency no longer had Medicare (federal health insurance program for individuals aged 65 or older and younger people with specific disabilities) [L&C] patients. During a record review and interview on 4/13/26 at 1:36 pm the Alternate Administrator/ Supervising Nurse reviewed the Discharged Patient List dated 4/12/25- 4/12/26 from the parent and branch locations. The Alternate Administrator/ Supervising Nurse said all of the patients from the agency that were discharged in the last 12 months were PAS patients. The Alternate Administrator/ Supervising Nurse said it had been a while since the agency had any L&C patients. The Alternate Administrator/ Supervising Nurse said the last L&C patient the agency had was around 2021. The Alternate Administrator/ Supervising Nurse said after the pandemic (epidemic of an infectious disease that has spread across a large region) started the L&C patients just stopped. During a record review and interview on 4/14/26 at 1:15 pm the Alternate Administrator/ Supervising Nurse reviewed the Inactive [Discharged] Patient List from 2023, 2024, and 2025 from the parent and branch locations. The Alternate Administrator/ Supervising Nurse said the agency had not had any L&C patients since 2023. The Alternate Administrator/ Supervising Nurse said the agency has not been getting referrals for L&C patients and there had been a staffing issue at the agency. The Alternate Administrator/ Supervising Nurse said it was currently up in the air and the agency was thinking about admitting L&C patients. Attempted a telephone interview on 4/14/26 at 1:58 pm with the Administrator. The call went straight to voice mail. Message left identifying surveyor and requested a call back. Attempted a telephone interview on 4/14/26 at 2:20 pm with the Administrator. The call went straight to voice mail. Message left identifying surveyor and requested a call back. Record review of a Scope of Services policy dated 1/13/18 indicated “agency, provides health and home care services which include professional nursing and personal care, as well as, physical/occupational therapy services and social services. All services are provided in accordance with current laws and regulations. … Services provided: Skilled Nursing Services: Registered Nurses and Licensed Vocational Nurses provided skilled nursing services that cannot be performed safely and effectively by non-professional personnel. These services include evaluations, care planning, and performing procedures/treatments. … Contract services: Physical therapy and social work services are provided by contract providers. … Criteria: … Individuals may receive a single type of service or a combination of services depending on the complexity of needs and the authorization of services …””