Accentcare Home Health of College Station

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review on 5 clients receiving care through agency and staff interviews, the agency failed to ensure skilled professionals-maintained responsibility to prepare clinical notes in that the agency did not enforce a written policy for implementation of care for required documentation on significant events or notification of EMS assistance for Client #2. PTA 1 failed to document significant events at home visit of Client #2, which resulted in Client need to EMS assistance and hospitalization. Record review of Client #2 visit notes with PT staff, including the visit of PTA 1 on 3/20/26 when Client was sent to hospital. After review of documentation surveyor was unable to locate any record noted of Client #2 status upon home visit or no notification of EMS mentioned within the Client record. Further record review of other home visit documentation with other PT staff from agency with Client #2 revealed narrative documentation to include Client status, his mobility, participation in PT activities, etc. Review of documentation within records did not reveal home visit on 3/20/26 for PTA 1 with Client #2, which reflects no visit occurred on this date with this Client by PTA 1. Interview with Administrator on 6.24.26 at 10:00 AM in reference to policy that addressed when an emergency occurs with the Client that warrants 911 or emergency assistance, what was the policy for this. Administrator stated she does not know offhand and will reach out to agency staff who can assist in locating the policy needed. Interview with Administrator on 6.24.26 at 10:00 AM on clarification of how care is documented with agency staff, for instance PT vs. PTA on home visits. Asked Administrator what is required for the visit in reference to the documentation. Asked Administrator if there is specific documentation that is required by agency for each specialty for home visits. Administrator stated she does not know exactly what they are trained in for PT, so she will contact the Senior Clinical Instructor, who is responsible for training physical therapy staff. Administrator stated she will set up an interview via Teams with questions/answers. Interview with Senior Clinical Instructor via Teams on 6.24.26 at 10:55 AM in reference to visit notes pertaining to PT, surveyor asked about clarification on difference in PT vs. PTA documentation. Sr Clinical Instructor stated the PT staff are trained to use SOAP documentation which is built into the visit note. She stated she S (subjective) O (observation) A (assessment) P (plan) addresses the status of the client during the home visit to include how they participated, etc. She stated that the narrative note is included when additional documentation is required, for instance a change in Client status, need for notification of physician, call to the agency due to some concerns or even if emergency services are necessary. She also included that if this is required documentation in coordination notes it is necessary to include the additional information which occurred during the home visit. Asked Sr Clinical Instructor if this is required for all PT staff, which she stated that all staff are trained to document this and must be included in the Client record with all the necessary information. Sr. Clinical Instructor also shared the computer screen of Client #2 and provided details on where the notes should be located as well as provided an explanation how the documentation is expected to be viewed. Interview with Administrator on 6.24.26 at 11:30 AM, surveyor asked Administrator if she was aware of the agency policy on documentation on emergency care, which she stated she couldn’t recall offhand, however she stated all agency staff are required to contact emergency services at any time a client needs assistance. The Administrator also included the agency should be made aware of any change in status, especially if EMS is necessary for a Client. Review of agency policy, “Emergency Care Protocols” dated 11/10//25 revealed, procedure: professional personnel finding a patient needing immediate medical care shall contact the emergency response system and stay with the patient, giving necessary care following Section 15 (Emergencies) of the VNAA Manual unit emergency services arrive. The physician or allowed practitioner and Agency’s Clinical Manager are contacted as soon as possible. Clinical documentation should be included in Client records.”