Enhabit Home Health

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure Patients were free from neglect for 1 of 14 patients reviewed (Patient #1) in that: The agency failed to follow up with Patient #1’s physician regarding the left heel deep tissue injury found on start of care on 8/16/2024 of Client 1. The agency failed to ensure a complete skin assessment, including Patient #1’s heels was performed on 8/27/2024, 9/3/2024 and 9/18/2024, resulting in a Stage 4 pressure ulcer (the most severe stage of a pressure ulcer, characterized by full thickness tissue loss exposing underlying muscle, tendon, or bone, often with significant damage to surrounding tissue, and a high risk of infection due to the deep nature of the wound; typically requires immediate medical attention and may necessitate surgical intervention to manage the damage) to both heels. This failure placed agency patients at an increased risk of neglect by agency staff and resulted in Client #1’s worsened pressure injuries. Findings included: Record review of a care plan for 8/16/2024-10/14/2024 indicated Patient #1 was admitted to the agency on 8/16/2024 with diagnosis including urinary tract infection, high blood pressure, and heart failure (the heart does not pump blood as well as it should). The care plan indicated Patient #1 was to receive skilled nursing once a week for one week, once every 2 weeks for 2 weeks and once a week for two weeks. The care plan indicated physical therapy would see Patient #1 effective 8/18/2024 twice a week for two weeks and once a week for one week. The care plan indicated the skilled nurse would observe and assess skin integrity and hygiene, provide skin teaching for signs and symptoms, medication management, pathophysiology, modification of risk factors and self-management. The plan of care did not indicate any abnormal skin integrity findings upon admission. Record review of a complaint report dated 9/23/2024 indicated physician G notified the agency Patient #1 had been on services since 8/16/2024, saw physician G on 9/12/2024 where he discovered stage 4 pressure ulcers (the most severe stage of a pressure ulcer, characterized by full thickness tissue loss exposing underlying muscle, tendon, or bone, often with significant damage to surrounding tissue, and a high risk of infection due to the deep nature of the wound; typically requires immediate medical attention and may necessitate surgical intervention to manage the damage) on both heels. The complaint report indicated written verbal given to LVN A as she saw Patient #1 twice after the start of care where RN B documented in her narrative that Patient #1 had a sore on her left heel and tenderness to palpation. The complaint report indicated LVN A was educated on thoroughly checking skin whether patient has diabetes or not and more education was assigned for the LVN to complete. The complaint report indicated the skin assessment in the electronic medical record was discussed with all staff members. LVN A was placed on a performance improvement plan and 2 in home visits would be completed with the staff member to ensure she was performing skin assessments appropriately. Record review of a Counseling performance improvement plan indicated it was given to LVN A on 9/24/2024 for the reason of patient care. The plan indicated Patient #1 was on services with the agency, LVN A saw her twice and there was no documentation about checking skin integrity. The plan indicated Patient #1 went to see her podiatrist (foot doctor) where he found two stage 4 pressure ulcers on both heels. The plan indicated it was imperative a thorough skin assessment of all patients is completed and documented accordingly. The Counseling performance improvement plan was signed by LVN A. Record review of a physicians note dated 9/11/2024 from physician G indicated Patient #1 had bilateral pressure ulcers, unstageable due to eschar (a wound that cannot be accurately staged because its depth is obscured by a thick layer of scar tissue). The note indicated Patient #1 had not had treatment as far as her blood flow goes and she was referred from her primary care physician for elongated nails as well as posterior heel wounds bilaterally (both sides). The note indicated there was a stage IV eschar posterior heel bilateral. Record review of a Visit Note Report dated 8/16/2024 for admission and OASIS collection completed by RN B indicated under integumentary ulcer/wounds present. The visit note indicated Patient #1 had at least one unhealed pressure ulcer/injury at stage 2 (partial thickness skin loss, where the top layer of skin and part of the deeper layer are damaged, resulting in a red or pink wound bed without muscle or bone exposed) or higher or designated as unstageable (type of pressure injury where the wound bed is completely covered by a thick layer of eschar (dead tissue)). The visit note indicated Patient #1 had one current unhealed pressure ulcer/injury at unstageable: slough (layer of dead, yellow, or white tissue that accumulates on the surface of the wound) and or eschar (dead tissue) present. According to the narrative portion of the visit note RN B documented Patient #1’s family member noted Patient had a sore to her left heel and tenderness to palpation, no open wound noted but potential DTI (Deep tissue injury- a type of pressure sore that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones. Patient #1 reported putting something on the area but did not know what it was while in nursing facility. No orders noted or received by agency. RN B contacted the physician’s office and educated Patient #1 and her daughter on keeping pressure off the area, especially in bed and can do so by elevating the extremity to keep the heel off of the bed and prevent further deterioration. RN B educated to notify agency if pain increased, or any area started to open to the heel. RN B left voicemail for call back related to possible DTI to left heel. DN received call back a few hours later from the doctor’s nurse who said she was going to pass along information and if any orders were needed notify the agency. RN B was told Patient #1 was scheduled an office visit and would have doctor assess area. Record review of a visit note report for visit date 8/27/2024 completed by LVN A indicated the examination of skin revealed no abnormal findings. Record review of a visit note report for visit date 9/3/2024 completed by LVN A indicated the examination of skin revealed no abnormal findings. Record review of a client coordination report dated 9/13/2024 completed by RN D indicated Patient #1 had bilateral heel wounds per physician G. Please assess and document wounds, no wound care at this time. The note indicated he wanted “airflow to the heel” for now per the physician’s office. Record review of a visit note report for visit date 9/18/2024 completed by RN E indicated ulcer/wounds present. The note indicated Patient #1 had bilateral unstageable heel wounds. The note indicated measurements of the wounds were not taken due to no ruler available. The narrative did not indicate any teaching had been done regarding the wounds. During an interview on 2/12/2025 at 1:17 p.m., LVN A said she was a full-time field nurse with the agency. LVN A said she had access to orders and documentation in the patients charts while in the home. LVN A said she reviewed the orders and last several visit notes prior to seeing a patient. LVN A said the registered nurses did OASIS visits like the start of care and developed the plan of care/home health orders. LVN A said she had seen Patient #1. LVN A said she took Patient #1’s vital signs and a skin assessment but did not take off her shoes and look at her feet. LVN A said there were orders on the Patient #1’s plan of care to do a skin assessment as needed. LVN A said she did not know Patient #1 had any skin issues on her feet, she said the patient was not bed bound, was ambulatory and did not have constant pressure on her heels. LVN A said on start of care the registered nurse did mention something about the patients heels but could not recall if the issue was mentioned on the plan of care. LVN A said in this particular instance she just failed to look at the patients’ feet. LVN A said Patient #1 is alert and oriented but required prompts at times for answers because she was so soft spoken and quiet. LVN A said the agency encouraged her and prompted her to continue to look at patients’ heels, she said she could not recall if she had received more training, but she had been a nurse for 25 years and she knew to do skin assessments she just failed to do it on this one patient. During an interview on 2/12/2025 at 1:27 p.m., RN B said she completed the start of care OASIS assessment on Patient #1. RN B said she was told she had some pressure sores on her heels following a doctor’s appointment a couple of weeks later. RN B said if the patient had any sores or wounds, she noted this in her coordination note. RN B said if she noted on start of care any skin irregularities she would notify the physician, educated on pressure injuries, and put the best practice orders on the plan of care. RN B said typically there is mention on the plan of care if the patient is high risk for skin issues and mentioned in the narrative so that the next clinician could assess the issue. RN B said she completed a full head to toe assessment on Patient #1 during the start of care including assessment of her heels and there was no visible wound there (break in the skin or open wound) from what she can recall. RN B said patient #1 was ambulatory. RN B said she could not recall Patient #1’s mentation but said she had a family member in the home to assist with medications, meals etc. RN B said the agency did training on skin assessments and frequency of skin assessments. RN B said skin assessments should include any area of the skin that could have pressure and should always include the feet and heels. During an interview on 2/12/2025 at 1:55 p.m., the DON said RN B had mentioned in her note an issue with Patient #1’s left heel. The DON said the LVN’s should read the narrative from the note prior to follow up on any needs or concerns. The DON said the issue with Patient #1’s heels was reported to one of the clinical team leaders in the office and she was not sure if they followed up on the issue or not. The DON said the clinical team leader should have followed up with the physician to see if any new orders were needed for Patient #1’s heel. The DON said the clinicians put clinical notes in the electronic medical record that go to the work screen of the clinical team leaders and that is how they know what needs to be followed up on. The DON said after the podiatrist called to report the patient had pressure ulcers the clinician were educated regarding skin assessments and the need for follow up. The DON said to her knowledge until the podiatrist called the agency to report the wounds, the agency was not aware the patient had the 2 pressure sores. The DON said they were aware of the DTI found on the left heel during the start of care assessment. The DON said these wounds can happen in a very short period of time. The DON said she could see how the unassessed wounds to Patient #1’s heels could be seen as neglect by the agency. The DON said not assessing and teaching on Patient #1’s heel wounds could be seen as neglect. The DON said all kinds of neglect should be reported to HHSC. The DON said she did not report this incident to HHSC because there were no new wound care orders given at the time, education was given to staff and the employee who did not perform the assessments was placed on a performance improvement plan. The DON said it was important to keep patients safe from neglect. During an interview on 2/12/2025 at 6:05 p.m., Family member H said Patient #1 was discharged from a nursing home in July of 2024 where she had developed pressure sores to both of her heels. Family member H said the agency comes out twice a week to perform wound care and the wound care doctor performs the wound care once a week. Family member H said she thought when the home health agency first started coming to the home, they were waiting on a wound care doctor and imaging studies. During an interview on 9/13/2025 at 10:05 a.m., the administrator said she expected when the registered nurse went out a head-to-toe assessment be done plus vital signs etc. and any issues be reported to physician and office and to try and get orders. The administrator said she expected the clinicians and office to ensure coordination of care occur. The administrator said if the nurse is unable to reach the physician the nurse should ensure the clinical team leader, case manager or someone follows up on the issue she reported. The administrator said if a clinical note is entered in a patient’s electronic medical record that note goes to the clinical team leader for follow up. The administrator said if there is no clinical note put in the medical record, then no one would know about the concern except for the clinician who goes out on the next visit when she reads the note from the previous clinician. The administrator said if a skin issue is noted on start of care, she expected the next nurse that went out at the bare minimum assess the area. The administrator said no order is needed to assess an area of concern. The administrator said a DTI can go south quickly depending on the amount of pressure and how long the sore had been present. The administrator said prior to the start of care the agency was not aware Patient #1 had any wounds. The administrator said RN B called the patients doctor, no orders were given at that time, they said they were going to see patient #1 then give any orders. The administrator said no new orders were sent to the agency for Patient #1. The administrator said pictures are taken of open wounds and taken at the start of the open wound. The administrator said she did not see this incident as neglect because Patient #1 had the wounds prior to admission to the agency and no new orders were received for wound care only to assess the wound. During an interview on 2/13/2025 at 11:30 a.m., RN D said she received a note from physician G’s office on 9/12/2024. RN D said she thought it was a referral for wound care on Patient #1. RN D said she remembered on Patient #1’s admission the note said one of her heels were soft but no open wound. RN D said there was no documentation regarding her heels the next couple of visits. RN D said she then reached out to the office to see if any wound care needed to be done and the physicians nurse said the physician did not really want wound care to be done, he wanted her to offload her heels and for the nurses to keep an eye on the heels. RN D said she would have kept an eye out for the wounds after she noticed the heel was soft at start of care. RN D said technically in a four-week period if there was pressure on the wounds they could have worsened. RN D said Patient #1’s heels should have been looked at by the nurses on the subsequent visits. RN D said assessment is important because it was noted in the start of care of the possibility of the wound becoming worse. RN D said snapshot notes in the electronic medical record can be put in to pop up on the clinician’s side to view at every visit for reminders for example “assess heels” or “coordinate with doctor” that could have been put in the medical record when something needed to be assessed but not necessarily an order for wound care. RN D said skin assessments should be done at every visit including foot assessment especially if the patient is diabetic. RN D said if the patient has any type of skin impairment or wound the MD should be notified while the nurse is still in the patient’s home. Surveyor attempted to call RN E on 2/14/2024, left voicemail for return call. RN E is no longer an employee of the agency. During an interview on 2/14/2025 at 11:10 a.m., the DON said a wound assessment should include documentation of what the wound looks like, what the wound measurements are, if there is odor or drainage. The DON said wound measurements were part of wound assessment and normally done weekly. The DON said a thorough skin assessment should be completed head to toe. The DON said if a skin abnormality or open wound is found upon assessment measurements should be taken. The DON said she would have to look at agency policy for measurements of eschar. The DON said if the wound is not open pictures could be taken. The DON said pictures of wounds are taken weekly. The DON said she and the administrator were responsible for quality of care and ensuring clinicians followed agency policy and procedures. The DON said chart audits are completed quarterly by herself, the administrator, and the clinical team leaders. During an interview on 2/14/2025 at 3:49 p.m., LVN H said she was physician G’s nurse. LVN H said Patient #1 saw physician G for the first time on 9/11/2024. She said Patient #1’s history shows it was reported to them she had pressure ulcers since July of 2024. LVN H said Patient #1 had not been seen in their office since that initial visit on 9/11/2024. LVN H said physician G had not assessed the patient prior to 9/11/2024. LVN H said physician G called the agency to have them monitor the wounds, instruct to float the heels at all times and monitor the wounds for signs and symptoms of worsening. LVN G said it was documented in the physicians note Patient #1 had a non-healing open wound on the right heel and a non-healing wound on the left heel. LVN H said the note did not specify if the wound on the left heel was open or not. LVN G said she would assume physician G would want the wounds assessed and measured. Record review of a policy titled Service Delivery Wound ulcer management with wound etiologies dated 11/27/2024 indicated 3.2.1.5 the plan of care should include appropriate adjunctive therapies that have been identified as appropriate and supportive to the patients wound/ulcer management. 3.3 Subsequent assessments and evaluations: 3.3.3.1 at minimum, the wound/ulcer shall be measured using the following criteria for home health and hospice patients once a week or when the wound care is provided if wound care is ordered less often than once per week. 3.3.3.2 it is noted that wounds/ulcers may require more frequent measurements, based on the patient’s response to the wound/ulcer care, or if there is deterioration. 3.3.3.5 all wounds are numbered and measured individually. Disposable rulers are used to obtain measurements. If the wound is completely covered with necrotic material, then the depth can be reported as unable to assess. Record review of a policy titled Service Delivery Admission process and patient assessment dated 2/12/2025 indicated 4.5 the admitting professional 4.5.2 prioritizes patients’ problems and needs, develops, implements a nursing care plan. 4.5.4 communicates the plan for services to the patient, family and team members involved in the patients care, as appropriate. Record review of a policy titled Service Delivery Patient abuse, neglect and exploitation Texas dated 9/25/2024 indicated 2.3 neglect is the failure of a caregiver to supply the patient with necessary food, clothing, shelter or health care when reasonable able to do so or failure to protect the patient from conditions or actions that imminently and seriously endanger the patients physical and mental health when reasonably able to do so.”

“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 interview and record review, the agency failed to ensure the state agency was notified immediately, within 24 hours of an allegation of neglect for 1 of 14 patients reviewed for neglect. (Patient #1) The agency did not immediately notify the state agency of neglect when Patient #1’s skin integrity was not thoroughly assessed after the admission visit on 8/16/2025 until 9/26/24 after physician G notified the agency of stage 4 pressure ulcers (the most severe stage of a pressure ulcer, characterized by full thickness tissue loss exposing underlying muscle, tendon, or bone, often with significant damage to surrounding tissue, and a high risk of infection due to the deep nature of the wound; typically requires immediate medical attention and may necessitate surgical intervention to manage the damage) to bilateral (both) heels on 9/13/2024. This failure could place patients increased risk of neglect by agency staff and worsening wound status. Findings included: Record review of a complaint report dated 9/23/2024 indicated physician G notified the agency Patient #1 had been on services since 8/16/2024, saw physician G on 9/12/2024 where he discovered stage 4 pressure ulcers (the most severe stage of a pressure ulcer, characterized by full thickness tissue loss exposing underlying muscle, tendon, or bone, often with significant damage to surrounding tissue, and a high risk of infection due to the deep nature of the wound; typically requires immediate medical attention and may necessitate surgical intervention to manage the damage) on bilateral heels. The complaint report indicated written verbal given to LVN A as she saw Patient #1 twice after the start of care where RN B documented in her narrative that Patient #1 had a sore on her left heel and tenderness to palpation. The complaint report indicated LVN A was educated on thoroughly checking skin whether patient has diabetes or not and more education was assigned for the LVN to complete. The complaint report indicated the skin assessment in the electronic medical record was discussed with all staff members. LVN A was placed on a performance improvement plan and 2 in home visits would be completed with the staff member to ensure she is performing skin assessments appropriately. Record review of a care plan for 8/16/2024-10/14/2024 indicated Patient #1 was admitted to the agency on 8/16/2024 with diagnosis including urinary tract infection, high blood pressure, and heart failure. The care plan indicated Patient #1 was to receive skilled nursing once a week for one week, once every 2 weeks for 2 weeks and once a week for two weeks. The care plan indicated physical therapy would see Patient #1 effective 8/18/2024 twice a week for two weeks and once a week for one week. The care plan indicated the skilled nurse would observe and assess skin integrity and hygiene, provide skin teaching for signs and symptoms, medication management, pathophysiology, modification of risk factors and self-management. The plan of care did not indicate any abnormal skin integrity findings upon admission. Record review of a Counseling performance improvement plan indicated it was given to LVN A on 9/24/2024 for the reason of patient care. The plan indicated Patient #1 was on services with the agency, LVN A saw her twice and there was no documentation about checking skin integrity. The plan indicated Patient #1 went to see her podiatrist (foot doctor) where he found two stage 2 pressure ulcers on both heels. The plan indicated it was imperative a thorough skin assessment of all patients is completed and documented accordingly. The Counseling performance improvement plan was signed by LVN A. Record review of a physicians note dated 9/11/2024 from physician G indicated Patient #1 had bilateral pressure ulcers, unstageable due to eschar (type of pressure ulcer where the base of the wound is covered by a thick, black or brown scab called eschar). The note indicated Patient #1 had not had treatment as far as her blood flow goes and she was referred from her primary care physician for elongated nails as well as posterior heel wounds bilaterally (both heels). The note indicated there was a stage IV eschar posterior hell bilateral. Record review of a Visit Note Report dated 8/16/2024 for admission and OASIS collection completed by RN B indicated under integumentary ulcer/wounds present. The visit note indicated Patient #1 had at least one unhealed pressure ulcer/injury at stage 2 (partial thickness skin loss, where the top layer of skin and part of the deeper layer are damaged, resulting in a red or pink wound bed without muscle or bone exposed) or higher or designated as unstageable (type of pressure injury where the wound bed is completely covered by a thick layer of eschar (dead tissue)). The visit note indicated Patient #1 had one current unhealed pressure ulcer/injury at unstageable: slough (layer of dead, yellow, or white tissue that accumulates on the surface of the wound) and or eschar (dead tissue) present. According to the narrative portion of the visit note RN B documented Patient #1’s daughter noted Patient had a sore to her left heel and tenderness to palpation, no open wound noted but potential DTI (Deep tissue injury- a type of pressure sore that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones. Patient #1 reported putting something on the area but did not know what it was while in nursing facility. No orders noted or received by agency. RN B contacted the physician’s office and educated Patient #1 and her daughter on keeping pressure off the area, especially in bed and can do so by elevating the extremity to keep the heel off of the bed and prevent further deterioration. RN B educated to notify agency if pain increased, or any area started to open to the heel. RN B left voicemail for call back related to possible DTI to left heel. The skilled nurse received call back a few hours later from the doctor’s nurse who said she was going to pass along information and if any orders were needed notify the agency. RN B was told Patient #1 was scheduled an office visit and would have doctor assess area. Record review of a visit note report for visit date 8/27/2024 completed by LVN A indicated the examination of skin revealed no abnormal findings. Record review of a visit note report for visit date 9/3/2024 completed by LVN A indicated the examination of skin revealed no abnormal findings. Record review of a client coordination report dated 9/13/2024 completed by RN D indicated Patient #1 had bilateral heel wounds per physician G. Please assess and document wounds, no wound care at this time. The note indicated he wanted “airflow to the heel” for now per the physician’s office. Record review of a visit note report for visit date 9/18/2024 completed by RN E indicated ulcer/wounds present. The note indicated Patient #1 had bilateral unstageable heel wounds. The note indicated measurements of the wounds were not taken due to no ruler available. The narrative did not indicate any teaching had been done regarding the wounds. During an interview on 2/12/2025 at 1:17 p.m., LVN A said she was a full-time field nurse with the agency. LVN A said she had access to orders and documentation in the patients charts while in the home. LVN A said she reviewed the orders and last several visit notes prior to seeing a patient. LVN A said the registered nurses did OASIS visits like the start of care and developed the plan of care/home health orders. LVN A said she had seen Patient #1. LVN A said she took Patient #1’s vital signs and a skin assessment but did not take off her shoes and look at her feet. LVN A said there were orders on the Patient #1’s plan of care to do a skin assessment as needed. LVN A said she did not know Patient #1 had any skin issues on her feet, she said the patient was not bed bound, was ambulatory and did not have constant pressure on her heels. LVN A said on start of care the registered nurse did mention something about the patients heels but could not recall if the issue was mentioned on the plan of care. LVN A said in this particular instance she just failed to look at the patients’ feet. LVN A said Patient #1 was alert and oriented but required prompts at times for answers because she was so soft spoken and quiet. LVN A said the agency encouraged her and prompted her to continue to look at patients’ heels, she said she could not recall if she had received more training, but she had been a nurse for 25 years and she knew to do skin assessments she just failed to do it on this one patient. During an interview on 2/12/2025 at 1:27 p.m., RN B said she completed the start of care OASIS assessment on Patient #1. RN B said she was told she had some pressure sores on her heels following a doctor’s appointment a couple of weeks later. RN B said if the patient had any sores or wounds, she noted this in her coordination note. RN B said if she noted on start of care any skin irregularities, she would notify the physician, educated on pressure injuries, and put the best practice orders on the plan of care. RN B said typically there was mentioned on the plan of care if the patient is high risk for skin issues and mentioned in the narrative so that the next clinician could assess the issue. RN B said she completed a full head to toe assessment on Patient #1 during the start of care including assessment of her heels and there was no visible wound there (break in the skin or open wound) from what she can recall. RN B said patient #1 was ambulatory. RN B said she could not recall Patient #1’s mentation but said she had a family member in the home to assist with medications, meals etc. RN B said the agency did training on skin assessments and frequency of skin assessments. RN B said skin assessments should include any area of the skin that could have pressure and should always include the feet and heels. During an interview on 2/12/2025 at 1:55 p.m., the DON said RN B had mentioned in her note an issue with Patient #1’s left heel. The DON said the LVN’s should read the narrative from the note prior to follow up on any needs or concerns. The DON said the issue with Patient #1’s heels was reported to one of the clinical team leaders in the office and she was not sure if they followed up on the issue or not. The DON said the clinical team leader should have followed up with the physician to see if any new orders were needed for Patient #1’s heel. The DON said the clinicians put clinical notes in the electronic medical record that go to the work screen of the clinical team leaders and that was how they knew what needs to be followed up on. The DON said after the podiatrist called to report the patient had pressure ulcers the clinician were educated regarding skin assessments and the need for follow up. The DON said to her knowledge until the podiatrist called the agency to report the wounds, the agency was not aware the patient had the 2 pressure sores. The DON said they were aware of the DTI found on the left heel during the start of care assessment. The DON said these wounds can happen in a very short period of time. The DON said she could see how the unassessed wounds to Patient #1’s heels could be seen as neglect by the agency. The DON said not assessing and teaching on Patient #1’s heel wounds could be seen as neglect. The DON said all kinds of neglect should be reported to HHSC. The DON said she did not report this incident to HHSC because there were no new wound care orders given at the time, education was given to staff and the employee who did not perform the assessments was placed on a performance improvement plan. The DON said it was important to keep patients safe from neglect. During an interview on 2/12/2025 at 6:05 p.m., Family member H said Patient #1 was discharged from a nursing home in July of 2024 where she had developed pressure sores to both of her heels. Family member H said the agency comes out twice a week to perform wound care and the wound care doctor performed wound care once a week. Family member H said she thought when the home health agency first started coming to the home, they were waiting on a wound care doctor and imaging studies. During an interview on 9/13/2025 at 10:05 a.m., the administrator said she expected when the registered nurse went out a head-to-toe assessment be done plus vital signs etc. and any issues be reported to physician and office and to try and get orders. The administrator said she expected the clinicians and office to ensure coordination of care occur. The administrator said if the nurse was unable to reach the physician the nurse should ensure the clinical team leader, case manager or someone follows up on the issue she reported. The administrator said if a clinical note was entered in a patient’s electronic medical record that note goes to the clinical team leader for follow up. The administrator said if there was no clinical note put in the medical record, then no one would know about the concern except for the clinician who goes out on the next visit when she reads the note from the previous clinician. The administrator said if a skin issue was noted on start of care, she expected the next nurse that went out at the bare minimum assess the area. The administrator said no order was needed to assess an area of concern. The administrator said a DTI can go south quickly depending on the amount of pressure and how long the sore had been present. The administrator said prior to the start of care the agency was not aware Patient #1 had any wounds. The administrator said RN B called the patients doctor, no orders were given at that time, they said they were going to see patient #1 then give any orders. The administrator said no new orders were sent to the agency for Patient #1. The administrator said pictures are taken of open wounds and taken at the start of the open wound. The administrator said she did not see this incident as neglect because Patient #1 had the wounds prior to admission to the agency and no new orders were received for wound care only to assess the wound. During an interview on 2/13/2025 at 11:30 a.m., RN D said she received a note from physician G’s office on 9/12/2024. RN D said she thought it was a referral for wound care on Patient #1. RN D said she remembered on Patient #1’s admission the note said one of her heels were soft but no open wound. RN D said there was no documentation regarding her heels the next couple of visits. RN D said she then reached out to the office to see if any wound care needed to be done and the physicians nurse said the physician did not really want wound care to be done, he wanted her to offload her heels and for the nurses to keep an eye on the heels. RN D said she would have kept an eye out for the wounds after she noticed the heel was soft at start of care. RN D said technically in a four-week period if there was pressure on the wounds they could have worsened. RN D said Patient #1’s heels should have been looked at by the nurses on the subsequent visits. RN D said assessment was important because it was noted in the start of care of the possibility of the wound becoming worse. RN D said snapshot notes in the electronic medical record can be put in to pop up on the clinician’s side to view at every visit for reminders for example “assess heels” or “coordinate with doctor” that could have been put in the medical record when something needed to be assessed but not necessarily an order for wound care. RN D said skin assessments should be done at every visit including foot assessment especially if the patient is diabetic. RN D said if the patient has any type of skin impairment or wound the MD should be notified while the nurse is still in the patient’s home. Surveyor attempted to call RN E on 2/14/2024, left voicemail for return call. RN E was no longer an employee of the agency. During an interview on 2/14/2025 at 11:10 a.m., the DON said a wound assessment should include documentation of what the wound looks like, what the wound measurements are, if there is odor or drainage. The DON said wound measurements were part of wound assessment and normally done weekly. The DON said a thorough skin assessment should be completed head to toe. The DON said if a skin abnormality or open wound is found upon assessment measurements should be taken. The DON said she would have to look at agency policy for measurements of eschar. The DON said if the wound was not open pictures could be taken. The DON said pictures of wounds are taken weekly. The DON said she and the administrator were responsible for quality of care and ensuring clinicians followed agency policy and procedures. The DON said chart audits are completed quarterly by herself, the administrator, and the clinical team leaders. During an interview on 2/14/2025 at 3:49 p.m., LVN H said Patient #1 saw physician G for the first time on 9/11/2024. She said Patient #1’s history showed it was reported to them she had pressure ulcers since July of 2024. LVN H said Patient #1 had not been seen in their office since that initial visit on 9/11/2024. LVN H said physician G had not assessed the patient prior to 9/11/2024. LVN H said physician G called the agency to have them monitor the wounds, instruct to float the heels at all times and monitor the wounds for signs and symptoms of worsening. LVN H said it was documented in the physicians note Patient #1 had a non-healing open wound on the right heel and a non-healing wound on the left heel. LVN H said the note did not specify if the wound on the left heel was open or not. LVN H said she would assume physician G would want the wounds assessed and measured. Record review of a policy titled Service Delivery Patient abuse, neglect and exploitation Texas dated 9/25/2024 indicated 2.3 neglect is the failure of a caregiver to supply the patient with necessary food, clothing, shelter, or health care when reasonable able to do so or failure to protect the patient from conditions or actions that imminently and seriously endanger the patients physical and mental health when reasonably able to do so. 2.9 Reportable conduct is defined as: 2.9.1 abuse or neglect that causes or may cause death or harm to an individual receiving agency services. 2.13 Reports are called and / or mailed to the following agencies, as outlined in the procedure below: 2.12.2 Texas health and Human Services within 24 hours. 3.1 All agency employees are mandated to report allegations and suspected abuse, neglect and exploitation and must report 3.1.2 any allegation or reasonable cause to believe or suspect patient abuse, neglect, or exploitation.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care contained the required elements to cover all supplies and equipment required, patient specific interventions and education, and safety measures to protect against injury for 5 of 14 patient reviewed for plan of care. (Patient #1, Patient #11, Patient #12, Patient #13, and Patient #14) The agency did not ensure Patient #1’s POC included assessment, teaching, care, or safety precautions for Patient #1’s DTI (Deep tissue injury). The agency did not ensure Patient #11’s POC included what type of dialysis access the patient had, where Patient #11 received dialysis or how often. The agency did not ensure Patient #12’s POC included his dialysis access type, location, or how often he received dialysis. The POC did not include Patient #12’s foley catheter including type of catheter or orders for when to change the catheter. The agency did not ensure Patient #14’s POC included the location of her PICC line or any safety precautions for her PICC line. The POC did not include safety precautions for Eliquis (blood thinner). This failure could place patients at risk of worsening wounds, not recognizing symptoms of bleeding, and not receiving proper care/instruction leading to complications and hospitalization. Findings included: 1 Record review of a plan of care for certification period 8/16/2024-10/14/2024 indicated Patient #1 was admitted to the agency on 8/16/2024 with diagnosis including urinary tract infection, high blood pressure, and heart failure (heart does not pump blood as well as it should) . The care plan indicated Patient #1 was to receive skilled nursing once a week for one week, once every 2 weeks for 2 weeks and once a week for two weeks. The care plan indicated physical therapy would see Patient #1 effective 8/18/2024 twice a week for two weeks and once a week for one week. The care plan indicated the skilled nurse would observe and assess skin integrity and hygiene, provide skin teaching for signs and symptoms, medication management, pathophysiology, modification of risk factors and self-management. The plan of care did not mention assessment, care, teaching or safety precautions for Patient #1’s DTI assess and documented in the OASIS on admission. Record review of a Visit Note Report dated 8/16/2024 for admission and OASIS collection completed by RN B indicated under integumentary ulcer/wounds present. The visit note indicated Patient #1 had at least one unhealed pressure ulcer/injury at stage 2 (partial thickness skin loss, where the top layer of skin and part of the deeper layer are damaged, resulting in a red or pink wound bed without muscle or bone exposed) or higher or designated as unstageable (type of pressure injury where the wound bed is completely covered by a thick layer of eschar (dead tissue)). The visit note indicated Patient #1 had one current unhealed pressure ulcer/injury at unstageable: slough (layer of dead, yellow, or white tissue that accumulates on the surface of the wound) and or eschar (dead tissue) present. According to the narrative portion of the visit note RN B documented Patient #1’s daughter noted Client had a sore to her left heel and tenderness to palpation, no open wound noted but potential DTI (Deep tissue injury- a type of pressure sore that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones. Patient #1 reported putting something on the area but did not know what it was while in nursing facility. No orders noted or received by agency. RN B contacted the physician’s office and educated Patient #1 and her daughter on keeping pressure off the area, especially in bed and can do so by elevating the extremity to keep the heel off of the bed and prevent further deterioration. RN B educated to notify agency if pain increased, or any area started to open to the heel. RN B left voicemail for call back related to possible DTI to left heel. SN received call back a few hours later from the doctor’s nurse who said she was going to pass along information and if any orders were needed notify the agency. 2 Record review of a plan of care for certification period 12/27/2024-2/24/2025 indicated Patient #11 was admitted to the agency on 12/27/2024 with diagnosis including dementia (memory loss), high blood pressure, end stage kidney disease (kidneys no longer work by cleaning the blood of wastes and to maintain fluid balance) , and dependence on dialysis (treatment that removes waste and extra fluid from the blood when the kidneys aren’t working properly). The plan of care indicated Patient #11 was to receive skilled nursing once a week for six weeks. The plan of care did not include the type of dialysis access Patient #11 had, where Patient #11 received dialysis or how often she received dialysis. 3 Record review of a plan of care for certification period 1/9/2025-3/9/2025 indicated Patient #12 was admitted to the agency on 1/9/2025 with diagnosis including Fournier gangrene (rare, life threatening, rapidly progressive necrotizing fasciitis (flesh eating disease) that affects the genital, perianal, and perineal areas, a urologic emergency), open wound of scrotum and testes (male parts) , high blood pressure, end stage kidney disease. The plan of care indicated the skilled nurse was to observe and assess the genitourinary system (digestive system), provide teaching on signs and symptoms, hospitalization/emergency room risk reduction, medication management, pathophysiology (study of how diseases and injuries cause changes in the body’s functions) of the disease, modification of risk factors and self-management and wellness. The plan of care indicated the skilled nurse would provide instruction regarding best practices for UTI prevention including signs and symptoms, prevention, incontinence management, medication management, and catheter hygiene if applicable. The plan of care did not address Patient #12’s urinary catheter (a hollow tube inserted into the bladder used to drain urine to a bedside drainage bag). The plan of care did not indicate the type of urinary catheter or orders for catheter care. The plan of care did not address Patient #12’s dialysis including the type of dialysis, the access site, where dialysis was being provided and how often dialysis was being provided. Record review of a visit note report for admission and OASIS collection dated 1/9/0225 indicated Patient #12 had an indwelling foley catheter present and received peritoneal dialysis (treatment for kidney disease that uses the lining of the abdomen as a filter to remove waste products and excess fluid from the blood, a thin tube is surgically implanted into the abdomen). The note indicated Patient #12 had a foley catheter in place draining without complications and a tunneled catheter on the left chest wall. 4. Record review of a plan of care for certification period 1/29/2025-3/29/2025 indicated Patient #14 was admitted on 1/29/2025 with diagnosis including urinary tract infection and sepsis (a life-threatening complication of infection). The plan of care indicated the skilled nurse would see Patient #14 twice weekly for two weeks then once weekly for seven weeks. The plan of care indicated Patient #14 took Eliquis a blood thinner twice daily. The plan of care indicated orders for Patient #14’s PICC (peripherally inserted catheter to administer medications) but did not address the location of the PICC line The plan of care did not address bleeding precautions. During an interview on 2/13/2025 at 11:30 a.m. RN D said Patient #1’s heels should have been addressed at subsequent visits after the start of care. RN D said for patients with wounds they should have orders on the plan of care to address skin integrity. RN D said if a patient had a PICC line the plan of care should address if the patient had orders for infusion, dressing changes, frequency of infusion and flushes. RN D said if a patient had a urinary catheter the plan of care should address impaired genitourinary, size of the catheter and how often the skilled nurse needed to change the catheter. RN D said if a patient was on dialysis the plan of care should address what type of dialysis access, orders to monitor the dialysis site and how frequently the patient attends dialysis. RN D said for a patients PICC line the location of the PICC line should also be on the plan of care. RN D said the PICC line site needed to be assessed for redness, irritation, and migration. RN D said the assessing RN created the plan of care. RN D said safety precautions included fall precautions, diabetes precautions, high risk medications, bleeding precautions for blood thinners. RN D said safety precautions are specific to each patients needs. RN D said there should be safety precautions for implanted devices such as for dialysis and no blood pressures to PICC line site. RN D said a skin assessment should be completed at every visit to include a foot assessment especially if the patient is diabetic. RN D said all of these things are important for the care of the patient and their overall being. During an interview on 2/14/2024 at 11:10 a.m., the DON said the RN’s built the plan of cares. The DON said the plan of cares are then reviewed by clinical team leaders in the office which is a new process for the agency. The DON said previously they were reviewed by packet reviewers who were employed by the agency and worked from home to review the plan of care. The DON said the plan of care for a patient admitted with a PICC line should include management orders, medications infused, flushes and dressing change orders. The DON said the PICC line location and safety precautions related to the PICC should be addressed in the plan of care including infusion and blood precautions. The DON said if a patient wasis on dialysis, she expected to see on the plan of care the port site, no blood pressure-safety precautions, diet and weight precautions and parameters. The DON said there should be orders for the port site to be assessed. The DON said the frequency and days the patient received dialysis should be on the plan of care. The DON said if a patient had a urinary catheter the plan of care should include the size of the catheter, foley care orders, orders for changing the foley catheter and urinary / urinary tract infection teaching precautions. The DON said the plan of care is updated on start of care, resumption of care and recertification. The DON said the plan of care included physician’s orders for patient care. The DON said she and the administer were responsible for quality of care and to ensure the agency policy and procedures were being followed. The DON said chart audits were completed quarterly by herself, the administrator, and the clinical team leaders. The DON said the reason these plans of cares had missing items was due to lack of education on the part of the nurses making and reviewing the plan of care. During an interview on 2/14/2025 at 11:36 a.m., the administrator said the plan of care review process changed in January of this year and all plan of cares are now reviewed by clinical team leaders and in the last couple of weeks she had reviewed quite a few to assist. The administrator said the plan of care should have the location of the PICC line, how many lumens the PICC line had, orders for flushing the PICC line, orders for what medication is being administered in the PICC line, orders for PICC line dressing changes, safety precautions including sterile technique dressing changes and blood pressure precautions. The administrator said if the patient was on a blood thinner the plan of care should include bleeding precautions. The administrator said if a patient had a urinary catheter the plan of care should include the type, size, frequency of changes and when the next change is due, and any orders for catheter flushes or urinalysis collection. The administrator said if the patient is on dialysis the location of the port or graft should be on the plan of care as well as orders for assessment of the site. The administrator said she did not want to answer whether or not the frequency at which the patient received the dialysis or where the patient received the dialysis should be on the plan of care. The administrator said the plan of care should include safety precautions including no blood pressure in arm of port or graft for a patient who received dialysis. The administrator said wound measurements should be done weekly as well as pictures. The administrator said she and the DON were responsible for overseeing the agency including the overall quality of care. Record review of a policy titled Service Delivery Physician’s Role dated 12/18/2024 indicated 2.1 the plan of care is a written plan developed with the participation of professional staff and the patient, in consultation with and authorized by the physician that supports the patients’ medical, nursing, and psychosocial needs in the home setting and services as the basis of care delivery. 2.1.1 The plan includes all pertinent diagnosis, mental status, types of services and equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications, treatments, safety measures to protect against injury, instructions for timely discharge and referral, description of the patients risk for emergency department visits and hospital re-admissions with all necessary interventions to address underlying risk factors, information related to any advanced directives and another other appropriate items.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation and interview, the administrator failed to be responsible for all day-to day operations of the agency in that: 1. The agency did not immediately notify the state agency of neglect when Client #1’s skin integrity was not thoroughly assessed after the admission visit on 8/16/2025 until 9/26/24 after physician G notified the agency of stage 4 pressure ulcers to bilateral heels on 9/13/2024. 2. The agency did not ensure Client #1’s POC included assessment, teaching, care, or safety precautions for Client #1’s DTI (Deep tissue injury). 3. The agency did not ensure Client #11’s POC included what type of dialysis access the client had, where Client #11 received dialysis or how often. 4. The agency did not ensure Client #12’s POC included his dialysis access type, location, or how often he received dialysis. The POC did not include Client #12’s indwelling urinary catheter (tube inserted into the bladder to drain urine) including type of catheter or orders for when to change the catheter. 5. The agency did not ensure Client #14’s POC included the location of her PICC line or any safety precautions for her PICC line. The POC did not include safety precautions for Eliquis (blood thinner). These failures could prevent the agency from identifying potential problems and implementing corrective actions to ensure the health and safety of the patients. Findings included: Record review of a policy titled Agency Operations Director of Operations Administrator dated 10/24/2024 indicated, 3.1.1 the Director of operations organized and directed the ongoing functions of the agency at all times…3.2.2 oversaw care delivery and patient outcomes to confirm care meets the patient’s needs. 3.2.3.3 Compliance with established policies and procedures. 3.2.3.4 Compliance with the patients plans of care. 1 Record review of a complaint report dated 9/23/2024 indicated physician G notified the agency Client #1 had been on services since 8/16/2024, saw physician G on 9/12/2024 where he discovered stage 4 pressure ulcers (the most severe stage of a pressure ulcer, characterized by full thickness tissue loss exposing underlying muscle, tendon, or bone, often with significant damage to surrounding tissue, and a high risk of infection due to the deep nature of the wound; typically requires immediate medical attention and may necessitate surgical intervention to manage the damage) on bilateral heels. The complaint report indicated written verbal given to LVN A as she saw Client #1 twice after the start of care where RN B documented in her narrative that Client #1 had a sore on her left heel and tenderness to palpation. The complaint report indicated LVN A was educated on thoroughly checking skin whether client has diabetes or not and more education was assigned for the LVN to complete. The complaint report indicated the skin assessment in the electronic medical record was discussed with all staff members. LVN A was placed on a performance improvement plan and 2 in home visits would be completed with the staff member to ensure she is performing skin assessments appropriately. Record review of a care plan for 8/16/2024-10/14/2024 indicated Client #1 was admitted to the agency on 8/16/2024 with diagnosis including urinary tract infection, high blood pressure, and heart failure. The care plan indicated Client #1 was to receive skilled nursing once a week for one week, once every 2 weeks for 2 weeks and once a week for two weeks. The care plan indicated physical therapy would see Client #1 effective 8/18/2024 twice a week for two weeks and once a week for one week. The care plan indicated the skilled nurse would observe and assess skin integrity and hygiene, provide skin teaching for signs and symptoms, medication management, pathophysiology, modification of risk factors and self-management. The plan of care did not indicate any abnormal skin integrity findings upon admission. Record review of a Counseling performance improvement plan indicated it was given to LVN A on 9/24/2024 for the reason of client care. The plan indicated Client #1 was on services with the agency, LVN A saw her twice and there was no documentation about checking skin integrity. The plan indicated Client #1 went to see her podiatrist (foot doctor) where he found two stage 2 pressure ulcers on both heels. The plan indicated it was imperative a thorough skin assessment of all clients is completed and documented accordingly. The Counseling performance improvement plan was signed by LVN A. Record review of a physicians note dated 9/11/2024 from physician G indicated Client #1 had bilateral pressure ulcers, unstageable due to eschar (type of pressure ulcer where the base of the base of the wound is covered by a thick, black or brown scab called eschar). The note indicated Client #1 had not had treatment as far as her blood flow goes and she was referred from her primary care physician for elongated nails as well as posterior heel wounds bilaterally (both heels). The note indicated there was a stage IV eschar posterior heels bilateral (both heels). Record review of a client coordination report dated 9/13/2024 completed by RN D indicated Client #1 had bilateral heel wounds per physician G. Please assess and document wounds, no wound care at this time. The note indicated he wanted “airflow to the heel” for now per the physician’s office. Record review of a Visit Note Report dated 8/16/2024 for admission and OASIS collection completed by RN B indicated under integumentary ulcer/wounds present. The visit note indicated Client #1 had at least one unhealed pressure ulcer/injury at stage 2 (partial thickness skin loss, where the top layer of skin and part of the deeper layer are damaged, resulting in a red or pink wound bed without muscle or bone exposed) or higher or designated as unstageable (type of pressure injury where the wound bed is completely covered by a thick layer of eschar (dead tissue)). The visit note indicated Client #1 had one current unhealed pressure ulcer/injury at unstageable: slough (layer of dead, yellow, or white tissue that accumulates on the surface of the wound) and or eschar (dead tissue) present. According to the narrative portion of the visit note RN B documented Client #1’s daughter noted Client had a sore to her left heel and tenderness to palpation, no open wound noted but potential DTI (Deep tissue injury- a type of pressure sore that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones. Client #1 reported putting something on the area but did not know what it was while in nursing facility. No orders noted or received by agency. RN B contacted the physician’s office and educated Client #1 and her daughter on keeping pressure off the area, especially in bed and can do so by elevating the extremity to keep the heel off of the bed and prevent further deterioration. RN B educated to notify agency if pain increased, or any area started to open to the heel. RN B left voicemail for call back related to possible DTI to left heel. DN received call back a few hours later from the doctor’s nurse who said she was going to pass along information and if any orders were needed notify the agency. RN B was told Client #1 was scheduled an office visit and would have doctor assess area. Record review of a visit note report for visit date 8/27/2024 completed by LVN A indicated the examination of skin revealed no abnormal findings. Record review of a visit note report for visit date 9/3/2024 completed by LVN A indicated the examination of skin revealed no abnormal findings. Record review of a visit note report for visit date 9/18/2024 completed by RN E indicated ulcer/wounds present. The note indicated Client #1 had bilateral unstageable heel wounds. The note indicated measurements of the wounds were not taken due to no ruler available. The narrative did not indicate any teaching had been done regarding the wounds. During an interview on 2/12/2025 at 1:17 p.m., LVN A said she was a full-time field nurse with the agency. LVN A said she had access to orders and documentation in the client’s charts while in the home. LVN A said she reviewed the orders and last several visit notes prior to seeing a client. LVN A said the registered nurses did OASIS visits like the start of care and developed the plan of care/home health orders. LVN A said she had seen Client #1. LVN A said she took Client #1’s vital signs and a skin assessment but did not take off her shoes and look at her feet. LVN A said there were orders on the Client #1’s plan of care to do a skin assessment as needed. LVN A said she did not know Client #1 had any skin issues on her feet, she said the client was not bed bound, was ambulatory and did not have constant pressure on her heels. LVN A said on start of care the registered nurse did mention something about the client’s heels but could not recall if the issue was mentioned on the plan of care. LVN A said in this particular instance she just failed to look at the clients’ feet. LVN A said Client #1 is alert and oriented but required prompts at times for answers because she was so soft spoken and quiet. LVN A said the agency encouraged her and prompted her to continue to look at clients’ heels, she said she could not recall if she had received more training, but she had been a nurse for 25 years and she knew to do skin assessments she just failed to do it on this one client. During an interview on 2/12/2025 at 1:27 p.m., RN B said she completed the start of care OASIS assessment on Client #1. RN B said she was told she had some pressure sores on her heels following a doctor’s appointment a couple of weeks later. RN B said if the client had any sores or wounds, she noted this in her coordination note. RN B said if she noted on start of care any skin irregularities she would notify the physician, educated on pressure injuries, and put the best practice orders on the plan of care. RN B said typically there is mention on the plan of care if the client is high risk for skin issues and mentioned in the narrative so that the next clinician could assess the issue. RN B said she completed a full head to toe assessment on Client #1 during the start of care including assessment of her heels and there was no visible wound there (break in the skin or open wound) from what she can recall. RN B said Client #1 was ambulatory. RN B said she could not recall Client #1’s mentation but said she had a family member in the home to assist with medications, meals etc. RN B said the agency did training on skin assessments and frequency of skin assessments. RN B said skin assessments should include any area of the skin that could have pressure and should always include the feet and heels. During an interview on 2/12/2025 at 1:55 p.m., the DON said RN B had mentioned in her note an issue with Client #1’s left heel. The DON said the LVN’s should read the narrative from the note prior to follow up on any needs or concerns. The DON said the issue with Client #1’s heels was reported to one of the clinical team leaders in the office and she was not sure if they followed up on the issue or not. The DON said the clinical team leader should have followed up with the physician to see if any new orders were needed for Client #1’s heel. The DON said the clinicians put clinical notes in the electronic medical record that go to the work screen of the clinical team leaders and that is how they know what needs to be followed up on. The DON said after the podiatrist called to report the client had pressure ulcers the clinician were educated regarding skin assessments and the need for follow up. The DON said to her knowledge until the podiatrist called the agency to report the wounds, the agency was not aware the client had the 2 pressure sores. The DON said they were aware of the DTI found on the left heel during the start of care assessment. The DON said these wounds can happen in a very short period of time. The DON said she could see how the unassessed wounds to Client #1’s heels could be seen as neglect by the agency. The DON said not assessing and teaching on Client #1’s heel wounds could be seen as neglect. The DON said all kinds of neglect should be reported to HHSC. The DON said she did not report this incident to HHSC because there were no new wound care orders given at the time, education was given to staff and the employee who did not perform the assessments was placed on a performance improvement plan. The DON said it was important to keep clients safe from neglect. During an interview on 2/12/2025 at 6:05 p.m., Family member H said Client #1 was discharged from a nursing home in July of 2024 where she had developed pressure sores to both of her heels. Family member H said the agency comes out twice a week to perform wound care and the wound care doctor performs the wound care once a week. Family member H said she thought when the home health agency first started coming to the home, they were waiting on a wound care doctor and imaging studies. During an interview on 9/13/2025 at 10:05 a.m., the administrator said she expected when the registered nurse went out a head-to-toe assessment be done plus vital signs etc. and any issues be reported to physician and office and to try and get orders. The administrator said she expected the clinicians and office to ensure coordination of care occur. The administrator said if the nurse is unable to reach the physician the nurse should ensure the clinical team leader, case manager or someone follows up on the issue she reported. The administrator said if a clinical note is entered in a client’s electronic medical record that note goes to the clinical team leader for follow up. The administrator said if there is no clinical note put in the medical record, then no one would know about the concern except for the clinician who goes out on the next visit when she reads the note from the previous clinician. The administrator said if a skin issue is noted on start of care, she expected the next nurse that went out at the bare minimum assess the area. The administrator said no order is needed to assess an area of concern. The administrator said a DTI can go south quickly depending on the amount of pressure and how long the sore had been present. The administrator said prior to the start of care the agency was not aware Client #1 had any wounds. The administrator said RN B called the clients doctor, no orders were given at that time, they said they were going to see Client #1 then give any orders. The administrator said no new orders were sent to the agency for Client #1. The administrator said pictures are taken of open wounds and taken at the start of the open wound. The administrator said she did not see this incident as neglect because Client #1 had the wounds prior to admission to the agency and no new orders were received for wound care only to assess the wound. During an interview on 2/13/2025 at 11:30 a.m., RN D said she received a note from physician G’s office on 9/12/2024. RN D said she thought it was a referral for wound care on Client #1. RN D said she remembered on Client #1’s admission the note said one of her heels were soft but no open wound. RN D said there was no documentation regarding her heels the next couple of visits. RN D said she then reached out to the office to see if any wound care needed to be done and the physicians nurse said the physician did not really want wound care to be done, he wanted her to offload her heels and for the nurses to keep an eye on the heels. RN D said she would have kept an eye out for the wounds after she noticed the heel was soft at start of care. RN D said technically in a four-week period if there was pressure on the wounds they could have worsened. RN D said Client #1’s heels should have been looked at by the nurses on the subsequent visits. RN D said assessment is important because it was noted in the start of care of the possibility of the wound becoming worse. RN D said snapshot notes in the electronic medical record can be put in to pop up on the clinician’s side to view at every visit for reminders for example “assess heels” or “coordinate with doctor” that could have been put in the medical record when something needed to be assessed but not necessarily an order for wound care. RN D said skin assessments should be done at every visit including foot assessment especially if the client is diabetic. RN D said if the client has any type of skin impairment or wound the MD should be notified while the nurse is still in the client’s home. Surveyor attempted to call RN E on 2/14/2024, left voicemail for return call. RN E is no longer an employee of the agency. During an interview on 2/14/2025 at 11:10 a.m., the DON said a wound assessment should include documentation of what the wound looks like, what the wound measurements are, if there is odor or drainage. The DON said wound measurements were part of wound assessment and normally done weekly. The DON said a thorough skin assessment should be completed head to toe. The DON said if a skin abnormality or open wound is found upon assessment measurements should be taken. The DON said she would have to look at agency policy for measurements of eschar. The DON said if the wound is not open pictures could be taken. The DON said pictures of wounds are taken weekly. The DON said she and the administrator were responsible for quality of care and ensuring clinicians followed agency policy and procedures. The DON said chart audits are completed quarterly by herself, the administrator, and the clinical team leaders. During an interview on 2/14/2025 at 3:49 p.m., LVN H said Client #1 saw physician G for the first time on 9/11/2024. She said Client #1’s history shows it was reported to them she had pressure ulcers since July of 2024. LVN H said Client #1 had not been seen in their office since that initial visit on 9/11/2024. LVN H said physician G had not assessed the client prior to 9/11/2024. LVN H said physician G called the agency to have them monitor the wounds, instruct to float the heels at all times and monitor the wounds for signs and symptoms of worsening. LVN H said it was documented in the physicians note Client #1 had a non-healing open wound on the right heel and a non-healing wound on the left heel. LVN H said the note did not specify if the wound on the left heel was open or not. LVN H she would assume physician G would want the wounds assessed and measured. Record review of a policy titled Service Delivery Client abuse, neglect and exploitation Texas dated 9/25/2024 indicated 2.3 neglect is the failure of a caregiver to supply the client with necessary food, clothing, shelter, or health care when reasonable able to do so or failure to protect the client from conditions or actions that imminently and seriously endanger the clients physical and mental health when reasonably able to do so. 2.9 Reportable conduct is defined as: 2.9.1 abuse or neglect that causes or may cause death or harm to an individual receiving agency services. 2.13 Reports are called and / or mailed to the following agencies, as outlined in the procedure below: 2.12.2 Texas health and Human Services within 24 hours. 3.1 All agency employees are mandated to report allegations and suspected abuse, neglect and exploitation and must report 3.1.2 any allegation or reasonable cause to believe or suspect client abuse, neglect, or exploitation. 2 Record review of a plan of care for certification period 8/16/2024-10/14/2024 indicated Client #1 was admitted to the agency on 8/16/2024 with diagnosis including urinary tract infection, high blood pressure, and heart failure (heart does not pump blood as well as it should). The care plan indicated Client #1 was to receive skilled nursing once a week for one week, once every 2 weeks for 2 weeks and once a week for two weeks. The care plan indicated physical therapy would see Client #1 effective 8/18/2024 twice a week for two weeks and once a week for one week. The care plan indicated the skilled nurse would observe and assess skin integrity and hygiene, provide skin teaching for signs and symptoms, medication management, pathophysiology, modification of risk factors and self-management. The plan of care did not mention assessment, care, teaching or safety precautions for Client #1’s DTI assess and documented in the OASIS on admission. Record review of a Visit Note Report dated 8/16/2024 for admission and OASIS collection completed by RN B indicated under integumentary ulcer/wounds present. The visit note indicated Client #1 had at least one unhealed pressure ulcer/injury at stage 2 (partial thickness skin loss, where the top layer of skin and part of the deeper layer are damaged, resulting in a red or pink wound bed without muscle or bone exposed) or higher or designated as unstageable (type of pressure injury where the wound bed is completely covered by a thick layer of eschar (dead tissue)). The visit note indicated Client #1 had one current unhealed pressure ulcer/injury at unstageable: slough (layer of dead, yellow, or white tissue that accumulates on the surface of the wound) and or eschar (dead tissue) present. According to the narrative portion of the visit note RN B documented Client #1’s daughter noted Client had a sore to her left heel and tenderness to palpation, no open wound noted but potential DTI (Deep tissue injury- a type of pressure sore that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones. Client #1 reported putting something on the area but did not know what it was while in nursing facility. No orders noted or received by agency. RN B contacted the physician’s office and educated Client #1 and her daughter on keeping pressure off the area, especially in bed and can do so by elevating the extremity to keep the heel off of the bed and prevent further deterioration. RN B educated to notify agency if pain increased, or any area started to open to the heel. RN B left voicemail for call back related to possible DTI to left heel. SN received call back a few hours later from the doctor’s nurse who said she was going to pass along information and if any orders were needed notify the agency. 3 Record review of a plan of care for certification period 12/27/2024-2/24/2025 indicated Client #11 was admitted to the agency on 12/27/2024 with diagnosis including dementia (memory loss), high blood pressure, end stage kidney disease, and dependence on dialysis (treatment that removes waste and extra fluid from the blood when the kidneys aren’t working properly). The plan of care indicated Client #11 was to receive skilled nursing once a week for six weeks. The plan of care did not include the type of dialysis access Client #11 had, where Client #11 received dialysis or how often she received dialysis. 4 Record review of a plan of care for certification period 1/9/2025-3/9/2025 indicated Client #12 was admitted to the agency on 1/9/2025 with diagnosis including Fournier gangrene (rare, life threatening, rapidly progressive necrotizing fasciitis (flesh eating disease) that affects the genital, perianal, and perineal areas, a urologic emergency), open wound of scrotum and testes (male parts), high blood pressure, end stage kidney disease. The plan of care indicated the skilled nurse was to observe and assess the genitourinary system, provide teaching on signs and symptoms, hospitalization/emergency room risk reduction, medication management, pathophysiology of the disease, modification of risk factors and self-management and wellness. The plan of care indicated the skilled nurse would provide instruction regarding best practices for UTI prevention including signs and symptoms, prevention, incontinence management, medication management, and catheter hygiene if applicable. The plan of care did not address Client #12’s foley catheter. The plan of care did not indicate the type of urinary catheter or orders for catheter care. The plan of care did not address Client #12’s dialysis including the type of dialysis, the access site, where dialysis was being provided and how often dialysis was being provided. Record review of a visit note report for admission and OASIS collection dated 1/9/0225 indicated Client #12 had an indwelling foley catheter present and received peritoneal dialysis (treatment for kidney disease that uses the lining of the abdomen as a filter to remove waste products and excess fluid from the blood, a thin tube is surgically implanted into the abdomen). The note indicated Client #12 had a foley catheter in place draining without complications and a tunneled catheter on the left chest wall. 5 Record review of a plan of care for certification period 1/29/2025-3/29/2025 indicated Client #14 was admitted on 1/29/2025 with diagnosis including urinary tract infection and sepsis (a life-threatening complication of infection). The plan of care indicated the skilled nurse would see Client #14 twice weekly for two weeks then once weekly for seven weeks. The plan of care indicated Client #14 took Eliquis a blood thinner twice daily. The plan of care indicated orders for Client #14’s PICC (peripherally inserted catheter to administer medications) but did not address the location of the PICC line The plan of care did not address bleeding precautions. During an interview on 2/13/2025 at 11:30 a.m. RN D said Client #1’s heels should have been addressed at subsequent visits after the start of care. RN D said for Clients with wounds they should have orders on the plan of care to address skin integrity. RN D said if a client had a PICC line the plan of care should address if the client had orders for infusion, dressing changes, frequency of infusion and flushes. RN D said if a client had a urinary catheter the plan of care should address impaired genitourinary, size of the catheter and how often the skilled nurse needed to change the catheter. RN D said if a client was on dialysis the plan of care should address what type of dialysis access, orders to monitor the dialysis site and how frequently the client attends dialysis. RN D said for a clients PICC line the location of the PICC line should also be on the plan of care. RN D said the PICC line site needed to be assessed for redness, irritation, and migration. RN D said the assessing RN created the plan of care. RN D said safety precautions included fall precautions, diabetes precautions, high risk medications, bleeding precautions for blood thinners. RN D said safety precautions are specific to each client’s needs. RN D said there should be safety precautions for implanted devices such as for dialysis and no blood pressures to PICC line site. RN D said a skin assessment should be completed at every visit to include a foot assessment especially if the client is diabetic. RN D said all of these things are important for the care of the client and their overall being. During an interview on 2/14/2024 at 11:10 a.m., the DON said the RN’s built the plan of cares. The DON said the plan of cares are then reviewed by clinical team leaders in the office which is a new process for the agency. The DON said previously they were reviewed by packet reviewers who were employed by the agency and worked from home to review the plan of care. The DON said the plan of care for a client admitted with a PICC line should include management orders, medications infused, flushes and dressing change orders. The DON said the PICC line location and safety precautions related to the PICC should be addressed in the plan of care including infusion and blood precautions. The DON said if a client is on dialysis, she expected to see on the plan of care the port site, no blood pressure-safety precautions, diet and weight precautions and parameters. The DON said there should be orders for the port site to be assessed. The DON said the frequency and days the client received dialysis should be on the plan of care. The DON said if a client had a urinary catheter the plan of care should include the size of the catheter, foley care orders, orders for changing the foley catheter and urinary / urinary tract infection teaching precautions. The DON said the plan of care is updated on start of care, resumption of care and recertification. The DON said the plan of care included physician’s orders for client care. The DON said she and the administer were responsible for quality of care and to ensure the agency policy and procedures were being followed. The DON said chart audits were completed quarterly by herself, the administrator, and the clinical team leaders. The DON said the reason these plans of cares had missing items was due to lack of education on the part of the nurses making and reviewing the plan of care. During an interview on 2/14/2025 at 11:36 a.m., the administrator said the plan of care review process changed in January of this year and all plan of cares are now reviewed by clinical team leaders and in the last couple of weeks she had reviewed quite a few to assist. The administrator said the plan of care should have the location of the PICC line, how many lumens the PICC line had, orders for flushing the PICC line, orders for what medication is being administered in the PICC line, orders for PICC line dressing changes, safety precautions including sterile technique dressing changes and blood pressure precautions. The administrator said if the client was on a blood thinner the plan of care should include bleeding precautions. The administrator said if a client had a urinary catheter the plan of care should include the type, size, frequency of changes and when the next change is due, and any orders for catheter flushes or urinalysis collection. The administrator said if the client is on dialysis the location of the port or graft should be on the plan of care as well as orders for assessment of the site. The administrator said she did not want to answer whether or not the frequency at which the client received the dialysis or where the client received the dialysis should be on the plan of care. The administrator said the plan of care should include safety precautions including no blood pressure in arm of port or graft for a client who received dialysis. The administrator said wound measurements should be done weekly as well as pictures. The administrator said she and the DON were responsible for overseeing the agency including the overall quality of care. Record review of a policy titled Service Delivery Physician’s Role dated 12/18/2024 indicated 2.1 the plan of care is a written plan developed with the participation of professional staff and the client, in consultation with and authorized by the physician that supports the clients’ medical, nursing, and psychosocial needs in the home setting and services as the basis of care delivery. 2.1.1 The plan includes all pertinent diagnosis, mental status, types of services and equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications, treatments, safety measures to protect against injury, instructions for timely discharge and referral, description of the clients risk for emergency department visits and hospital re-admissions with all necessary interventions to address underlying risk factors, information related to any advanced directives and another other appropriate items.”