Accentcare Home Health of Texas

“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 record review and interview, the agency failed to report to Texas HHS within 24 hours knowledge of alleged neglect which alleged clinician did not listen to heart and lung sounds of 1 (Client #1) of 3 patients. The failure placed patients at risk of receiving inadequate care, and/or risk of emotional harm. Findings include: Review of the Consumer Rights and Services Incident Investigation Worksheet for intake #1082455 reported by Agency 1’s Alternate Administrator located in 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 received date and time of 4/10/2026 at 2:34 PM. Further review revealed Agency 1 first learned of the incident 4/8/2026 at 4:01 PM. Review of the Complaint Report for Client #1 revealed Family 1 called Agency 1 on 4/8/2026 at 4:01 PM. Further review revealed under “Description” it read “SPOKE WITH [Family 1] REGARDING WHAT CLINICIANS ARE TO DO WHILE IN THE HOME REGARDING LISTENING TO THE HEART AND LUNGS. HE IS UPSET THAT NOT ONE CLINICIAN HAS SAT HER UP AND LISTENED TO HER HEART AND LUNGS SINCE SHE HAS BEEN ON SERVICES AND NOW SHE IS IN THE ER WITH FLUID OVERLOAD, DIZZINESS, [shortness of breath] AND SLURRED SPEECH. I DID EXPLAIN TO HIM THAT THEY ARE TO DO A COMPLETE HEAD TO TOE ASSISSMENT WITH EACH VISIT, WHICH INCLUDES LISTENING TO THE HEART AND LUNGS AND NOTIFY MD OF ANY ABNORMAL FINDINGS. HE STATED IF THEY WOULD HAVE LISTENED THEN THEY MAY NOT BE IN THE ER RIGHT NOW. HE STATES “I AMANGRY BECUASE I FEEL THIS COULD HAVE BEEN AVOIDED”. Further review of the Complaint Report revealed the following course of action by the agency: 4/9/2026 Alternate Administrator investigated accusations and notified Administrator of findings, decision made to initiate compliance call; 4/10/2026 compliance call conducted at 9AM, reviewed investigation which determined there were actions not performed by clinicians per company policy/expectations and based on findings, it was determined self-report to state would be done 4/10. Interview with the Administrator and Alternate Administrator on 6/22/2026 at 3:06 PM. The Administrator was asked about the agency’s process for receiving complaints. The Administrator stated the individual who took the complaint would enter it into the system and it would be forwarded to the Alternate Administrator for follow up. The Administrator was asked to review the above complaint and determine whether it provided sufficient cause to believe the patient may have been the subject of ANE. The Administrator stated that a review of the patient’s record would have been necessary before reaching that determination. The Surveyor asked why a self-report was not submitted to Texas HHS after the findings were identified during the chart review completed by the Alternate Administrator on 4/9/2026. The Alternate Administrator stated that a compliance meeting was held on 4/10/2026 to review the findings and it was determined at that time that a self-report should be submitted to Texas HHS. The Administrator was asked what the Agency’s policy was for self-reporting to Texas HHS and Administrator could not recall the exact time frame but stated the reporting was required within a short period. Surveyor reviewed the agency’s policy with the Administrator and Alternate Administrator which stated “Suppose an agency has cause to believe that a patient served by the Agency has been abused, neglected, or exploited by an agency employee, volunteer, or contractor. This includes any family members employed by the Agency. In that case, the Agency must report the information immediately, meaning within 24 hours.” Surveyor discussed with the Administrator and Alternate Administrator the distinction between having “cause to believe” and completing a full agency investigation. Following further discussion and clarification, both the Administrator and the Alternate Administrator acknowledged that the complaint should have been reported within 24 hours and agreed that the report was submitted late. The Surveyor asked the Administrator why it was important to report ANE to the state within the required 24-hour timeframe. The Administrator stated it was important to ensure that a proper investigation could be done, and it was also a condition of participation. The Administrator further stated, “we have to fend for the defenseless.” Review of the Agency’s policy “Reporting Abuse, Neglect, Fraud, or Exploitation of Clients” reference# C 2.1 last reviewed date 1/16/2026 under “Procedure” read in part “6. The Executive Director or designee will immediately (as soon as possible, but not more than twenty-four (24) hours after being notified of the incident) initiate an investigation of all alleged violations.” Further review revealed under “Texas Reporting Responsibilities”, under “Agency Self-Reporting to HHSC” read in part “Suppose an agency has cause to believe that a patient served by the Agency has been abused, neglected, or exploited by an agency employee, volunteer, or contractor. This includes any family members employed by the Agency. In that case, the Agency must report the information immediately, meaning within 24 hours, to: Effective September 1, 2023, all self-reported cases involving all payors shall be reported online to TULIP Online Licensure Application System | Texas Health and Human Services or by emailing ciicomplaints@hhs.texas.gov or by calling 1-800-458-9858.””