Theracare 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 a patient’s right to be free from neglect by unspecified contracted employee for one (Patient #10) out of 5 discharged patient records reviewed for providing services ordered in the plan of care, in that unspecified contracted employee failed to see Patient #10 as ordered by Physician Assistant. (Identifier 100) As a result of the failure the patient failed to receive therapy services from the contract company as ordered by the physician assistant. The failure placed the patient at an increased risk of degression in strength, constipation from lack of movement and continued or further neglect. Findings include: During the presurvey on 06/29/2026, review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) revealed a self-reported incident (for intake number 435118) dated 07/06/2023 and submitted by RN A revealed Patient #10’s Family Member 1 (FM 1) called on 07/05/2023 to report patient #10 had been hospitalized on 07/02/2023 due to being impacted (occurs when severe, prolonged constipation leaves a large, hard, dry mass of feces stuck in the rectum or lower colon. This blockage prevents normal bowel movements and causes a dangerous buildup of waste in the digestive tract) and stated it was her thinking that a missed physical therapy visit was the cause of the constipation. The self-reported incident also revealed that after agency investigations RN A discovered that therapy missed a scheduled visit for patient #10 on 06/29/2023 and it was not rescheduled. During an onsite investigation on 06/30/2026, review of the agency’s complaint records revealed a complaint report dated 07/03/2023 for Patient #10 and processed by RN A on 07/03/2023. Review of the complaint report revealed the description of the complaint as, “Patient’s FM1 called…the physical therapist did not show up last week and now the patient is in the hospital due to an impaction FM 1 said that the patient gets impacted when he is not moved around regularly…Patient #10 depends on a therapist to come at least two times a week for therapy and movement. FM 1 stated she knew he was on vacation, but she expected to at least have a different therapist to come, but no one did..” Intervention/Resolution comments: “RN A called [therapy company] and told them of the complaint and she was able to see that the usual therapist was indeed on vacation last week and stated it looked like Patient #10 requested the visit to be reassigned, but that it did not get done…” Complaint records also revealed a complaint report dated on 06/21/2023 for Patient #10 and processed by RN A on 06/22/2023. Review of the complaint report revealed the description of the complaint as. “ FM 1 called to report therapy has not been to see the patient since the first evaluation of 06/03/2023…it has almost been three weeks…Patient #10 is in need of therapy and she is unhappy we are not seeing him…” Intervention/Resolution comments: “…Upon investigation the past 3 weeks of physical therapy assistant visits had not been scheduled at all with no explanation. The last 2 weeks were just missed. The one for the week of 06/19/2023 was still blue. The rest going forward are scheduled. RN A scheduled the blue physical therapy assistant visit on 06/23/2026 to a male therapist and will call the scheduler, physical therapy and physical therapy assistant tomorrow to identify the problem and make sure the changes needed can be made. Also, increased patient’s frequency to 2x week through the end of the episode.” Patient #10: Record review of Patient #10’s clinical record revealed a plan of care with a start of care date of 01/23/2023 and certification period of 05/29/2023 to 07/27/2023. Review of the plan of care revealed that RN B signed and dated the plan of care on 05/24/2023. Continued review of the plan of care revealed a diagnosis of Hemiplegia (the severe or complete loss of motor function (paralysis) on one side of the body) following cerebral infarction (the death of brain tissue caused by a prolonged lack of blood flow and oxygen) affecting left nondominant side. Further review of the plan of care revealed physical therapy orders for 1 time a week for 9 weeks. Continued review of patient #10’s record revealed a coordination note from physical therapy dated 06/11/2023 for missed visit date 06/09/2023 and a second coordination note from physical therapy dated 06/18/2023 for missed visit date 06/16/2023. A coordination note dated 06/20/23 by RN B stated “nurse notified FM 1 last night to make an appointment for nursing discharge, but FM 1 was very upset due to patient hasn’t had a physical therapy visit in 2 weeks and was instructed to call the office. RN B stated she also notified the office by email that upper management needs to call her and speak to her regarding therapy and why no one has been there in 2 weeks…”. A coordination note dated 06/22/2023 by RN B stated, “FM 1 is upset office was supposed to call and speak to her regarding therapy and refused visit.” Further review of Patient #10’s record revealed a visit calendar and only receiving physical therapy on 06/03/2023, 06/22/2023 and 06/27/2023. Further review of Patient #10’s record revealed no documentation of hospital records. During a phone interview on 07/02/2026 at 1:15 PM with Patient #10 and FM 1, Patient #10 and FM 1 declined to comment on complaint and stated, “we have not been a patient of this home health agency in a few years and we have been with several other agencies since then and we do not remember if we had complaints about the nurses or therapist or not.” During an interview 07/03/2026 at 10:56 AM with Administrator, Alt Administrator/Supervising Nurse, Alt Supervising Nurse and Director of Clinical Quality, the Surveyor asked the Administrator who was responsible for making sure contracted missed visits were rescheduled. Administrator stated “scheduling.” The Surveyor asked who the scheduler was at the time the incident occurred, and the Administrator stated she was unaware since she was not employed with the agency at that time. The Surveyor asked what their agency’s processes were for ensuring those visits were rescheduled. Administrator stated, “the process is the scheduler is to do a requested report and then that is communicated with the administrator, and an order is generated, communication with field staff and trying to get the missed visit in by the end of the week.” Administrator stated, “agency has been working with therapy, and therapist are finally starting to send the agency emails with the missed visit note and stated there was a lag with that.” Administrator stated, “the majority of employees are fairly consistent, but there have been times when contract providers had not been reporting in real time.” The Surveyor asked why the processes were not followed. All the interview participants stated that none of them were employees at the time and did not know about this. The Surveyor asked what should have been done differently. The Alt Supervising Nurse stated, “since the new staff have been here, the agency doesn’t allow missed visits in the Medicare week, and they make it mandatory for a missed visit attempt to be rescheduled and the patient to be seen that week. If the patient stated, they do not want the visit to be rescheduled the alt supervising nurse reaches out to the patient to verify this.” Alt Supervising Nurse stated, “if she verified with the patient the employee in fact did not contact them, they would have a verbal warning and written warning, the agency would find a backup employee to see the patient and if it happened again the employee, rather agency employee or contract employee, would be terminated.” The Surveyor asked how the failure would affect a patient. Director of Clinical Quality stated, “it could set the patient back in all their care, especially if was therapy.” Administrator stated, “it could ultimately end in an unsafe discharge due to an exacerbation of a health situation and could lead to hospitalization and failure of the plan of care.” Review of agency policy titled, “Patient/Client Rights and Responsibilities revised on 05/01/2024 revealed the following: “Purpose: To ensure all patients/clients, representative (if any), and agency staff acknowledge, observe and implement the patient’s/client’s rights and responsibilities. “Procedure I: Agency staff will be responsible for knowing, observing, and implementing the patient’s/client’s rights, patient/client conduct, and patient/client responsibilities on a continuous basis. VI The patient/client has the right to:… B: Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect, and misappropriation of property.””

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview, the clinical manager failed to coordinate referrals for 1 (Patient #8) of 5 discharge records reviewed, in that, Patient #8 did not have documented coordination and communication regarding the delayed implementation of the ordered medical social worker evaluation, and the clinical manager failed to coordinate the referral as outlined in agency policies. As a result of this failure, the patient was placed at an increased risk of unmet psychosocial needs, delayed identification of barriers to care, delayed access to community resources, and adverse outcomes related to the delay in implementing ordered services. Findings include: Patient #8: During review of Patient #8’s clinical record revealed a plan of care with a start of care date of 12/31/2024 with a certification period of 6/29/2025 to 8/27/2025. It was signed and dated by RN B on 6/24/2025. It revealed a primary medical diagnosis of non-displaced fracture of greater trochanter of left femur (the bony prominence at the upper, outer side of the left thigh bone is cracked, but the fragments remain perfectly aligned with no separation). Further review of Patient #8’s clinical record revealed an order dated 7/10/2025 at 10:33 AM for medical social worker effective 7/6/2025 once a week for one week. Continued review of Patient #8 clinical record revealed no documentation of the medical social workers evaluation. An additional physician order dated 8/4/2025 stated medical social worker evaluation to be moved to 8/4/2025 due to staffing effective 8/3/2025 1 time a week for one week. Further review of Patient #8 clinical record revealed the medical social worker evaluation was completed on 8/6/2025. During interview on 07/03/2025 at 9:37 AM with Administrator, Alternate Administrator/Supervising Nurse, Alternate Supervising Nurse and Director of Clinical Quality the Surveyor asked who was responsible for ensuring referrals were processed and services ordered were provided. Administrators stated, “ultimately it is her responsibility, supervising nurse does the review and develops the plan of care and start of care. The Surveyor asked what was your agency policy for providing services ordered in the plan of care or provider orders. Administrator stated, “the agency follows CMS (Centers for Medicare and Medicaid Services) guidelines and evaluations are supposed to be initiated within 5 days of the start of care for all disciplines ordered.” The Surveyor asked, were you aware that your agency policy stated the medical social worker evaluations should be completed within four days. The Alternate Supervising Nurse and Administrator stated, “yes the agency is aware social work evaluations must be done within four days.” The Surveyor asked what was your timeline for documenting communication notes if those services were not provided at the times they were ordered. The Alternate Supervising Nurse stated, “if the evaluation moved week to week a coordination note should be placed in the chart and the physician and client should both be notified.” The Surveyor asked why their agency’s policies and timelines were not followed for Patient #8. The Administrator stated, “during that time the agency had an employee working all referrals and the Administrator stated that she has a stack of emails from that employee about her not processing referral orders.” Administrator also stated, “she has the lack of ability to provide oversight to each client and make sure everyone is getting the services that were ordered and referrals are being processed.” Administrator stated, “she has reported it to higher ups and stated that it needs to be corrected.” Administrator stated, “that the contracted companies need to be following up in real time letting them know that the evaluation was not done.” The Surveyor asked what should have been done differently. The Administrator stated, “the follow up needed to be in real time and it needed to be reported in their stand-up morning meeting and it should be addressed and completed within those five days.” Administrator stated, “if she was told they could have brainstormed.” Administrators stated. “She is having a hard time answering what could have been done differently because she was new at this time of the oversight.” Administrator stated, “personally she could have taken on sending the referral herself instead of having it under the employee that was responsible for it.” The Surveyor asked how the failure could adversely affect the patient. The Administrator stated, “agency staff had this discussion and stated the patients are under their care and with the continued occurrences of this and ultimately a patient in the home environment has the most severe risk of death at home, increased falls and injuries, delay of provider services like custodial care in the home, food resources that may be needed, home safety and lack of community programs.” Review of agencies policy titled “Medical Record Content” dated 05/07/2026 revealed the following, “Purpose: To ensure each medical record contains complete information which identifies the patient/client, describes problems and needs of the patient/client, justifies patient/client care, and accurately describes care provided, results, significant events and continuity among disciplines… E. Documentation/Communication for Continuity of Care… 3. Any referrals to internal or external providers/agencies;… 5. Any summaries or coordination notes between the Agency and others providing care or services;…” Review of agencies policy titled “Responsibilities of the Clinical Manager” dated 05/01/2024 revealed the following, “Purpose: To define the responsibilities of the Clinical Manager to ensure safe and appropriate delivery of patient/client care…Procedure: I. The Agency defines the responsibilities of the Clinical Manager to include, but not be limited to:… B. Coordinating patient/client care. C. Coordinating referrals…””