Affordable Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure 2 of 7 patients (#1, #4) received the home health services that were written in the individualized plan of care which was established by a Doctor of Medicine. The agency failed to ensure the client’s received the therapy services as ordered on the Plan of Care. This failure meant that Clients #1 and #4 were subjected to poor quality care, poor health outcomes, and inadequate care. Review of Patient 1’s Plan of Care for the certification period 02/23/2026 to 04/23/2026 revealed diagnoses of Cellulitis of Right Lower Limb (infection of right leg), Dementia, Moderate, with Agitation (a behavioral syndrome in cognitive decline affecting memory, motor activity, and emotional distress), Diabetes Mellitus with Diabetic Polyneuropathy (a chronic complication of impaired blood sugar metabolism leading to damage to peripheral nerves), Repeated Falls (2 or more unintentional landings on the floor within a 12 month period), Dependence on Wheelchair (necessary reliance on a wheelchair for mobility), and Long Term use of Anticoagulants (medication given beyond 6 months to prevent blood clots and stroke). Orders for care included nursing twice a week for nine weeks, physical therapy once a week for one week, twice a week for five weeks, and once a week for one week, and speech therapy once a week for one week, twice a week for four weeks, and once a week for one week. Review of Patient 1’s clinical record revealed no speech therapy services were provided as of the exit date of 03/11/2026. Review of the entire record found no evidence the physician was notified of the lack of services as ordered. An interview was conducted on 03.10.2026 at 1 pm during a home visit with Patient 1 and his family member (Identifier AA.) Patient 1 did not speak during the home visit to the surveyor. Patient 1’s Family Member AA stated no speech therapy had been provided by the agency, and Family Member AA had contacted the agency the week before the surveyor visit to ask when the speech therapy was going to be provided. Family Member AA stated Patient 1 needed more reminders to speak. Family Member AA stated Patient 1 had speech therapy with the previous home health agency and was concerned there had been no speech therapy provided since admission on 02/23/2026. Review of Patient 4’s Plan of Care for the certification period 01/12/2026 to 03/12/2026 revealed diagnoses of Nonrheumatic Aortic (valve) Stenosis (heart valve disease where the valve between the left ventricle and aorta cannot open fully, forcing the heart to work harder), Dissection of iliac artery (tear in the inner layer of the artery), Atrial Fibrillation (rapid, irregular heartbeats in the upper chambers of the heart), Diabetes Mellitus II (impaired blood sugar metabolism), Acute Respiratory Failure (lungs cannot adequately oxygenate the blood or remove carbon dioxide, Chronic Kidney Failure 3a (mild to moderate kidney failure where kidneys struggle to filter waste and fluid). Orders for care included nursing twice a week for two weeks and once a week for seven weeks, physical therapy once a week for one week, twice a week for five weeks, physical therapy once a week for one week to evaluate week of 01/12/2026, then twice a week for four weeks, and once a week for one week, and occupational therapy once a week for one week, to evaluate week of 01/12/2026 then twice a week for three weeks and once a week for one week. Review of Patient 4’s clinical record revealed no occupational therapy services were provided from the start of care of 01/12/2026 to discharge on 01/22/2026 when the patient was transferred and admitted to the hospital. Review of the entire record found no evidence the physician was notified of the lack of services as ordered. An interview was attempted with Patient 4 on 03/11/2026 at 2:13 PM and again at 3:00 PM. An interview was conducted on 03/11/2026 at 12:02 PM with RN A. RN A stated she evaluated Patient 1 during the start of care visit and determined the referral and order for speech therapy was appropriate for problems speaking clearly and in complete sentences, and memory issues. RN A stated the process of starting or providing therapy services is handled by the office staff. RN A stated she notified office staff of the patient’s needs after assessment and sometimes the agency only provided one therapy when 2 were ordered. RN A stated that was out of their “hands” after assessment and reporting into the office staff. An interview was conducted on 03/11/2026 at 3:45 PM with Office Manager B, Scheduler C, the Director of Nurses, and the Administrator. The surveyor reviewed the findings of the record reviews and home visits. The surveyor asked about the lack of ST and OT services for patients 1 and 4. Scheduler C stated she received the information from RN A and the procedure was to forward to administration who approved the therapy referrals to the contractors. Office Manager B stated they checked to be sure insurance authorization wasn’t an issue and to determine the number of visits needed. The Office Manager stated the policy was to send the referral to the therapy providers in 4 days after insurance verification and administration approval. Office Manger B stated there was no insurance authorization needed for Patient’s 1 and 4, and the administration made the decision to send only one therapy at a time. The Administrator stated they provided one therapy at a time because sometimes the patients don’t want so many people in their homes. The Administrator stated they would sometimes provide one therapy for the first month and the second for the second month of the certification period. The surveyor asked about the effect on the patients of the deficient practice. Office Manager B stated Patient 1’s family member AA called and complained about the lack of therapy services and the office manager took the information to the Administrator for approval to refer the patient for speech therapy services. The surveyor confirmed no speech therapy services had been provided as of the exit date of 03/11/2026 for Patient 1 with Office Manager B and the DON. Review of Agency policy titled: “Plan of Care TX.6” dated with a revision date of 04/04/2011 read in part: Purpose- To develop an individual Plan of Care to ensure client specific needs are met appropriately according to state and federal regulations. Policy – Agency will utilize data/information gathered during client assessments in the care planning process which involves the identification of client goas, actions or interventions that will resolve or alleviate the client’s problems and / or needs… The client/caregiver, as well as the client’s physician, will be encouraged to participate in the client’s care planning process to determine mutually agreed upon goals… Physician orders to include the discipline to render the services/treatments, the services or therapy modalities to be rendered and the frequency and duration of the visits to be made; specific procedures/treatments to be performed, including amount, frequency and duration…”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview the agency failed to conduct Performance improvement projects for 3 (2023, 2024, and 2025) of three years of the survey review period. The HHA failed to document the quality improvement projects undertaken for 2023, 2024, and 2025 and the reasons for conducting projects, and the measurable progress achieved on projects. This failure meant the agency was unable to use performance improvement projects to document improvements undertaken to correct identified problems and, if necessary, to revise policies. Patients were potentially subjected to poor quality of care, poor health outcomes, and inadequate care. Findings: During the entrance conference interview on 03/05/2026 the surveyor requested all QAPI documents including the Performance Improvement Projects for 2023, 2024, and 2025. Review of the white three ring binder that was undated provided by the agency on 03/11/2026 revealed no Performance Improvement Projects were documented. The surveyor requested additional performance improvement documentation on 03/11/2026. No performance improvement project documentation was provided by the end of the survey. An interview was conducted with the Administrator and DON and the Office Manager B on 03/11/2026 at 3:45 PM. The surveyor asked who was responsible for the agency’s Quality Improvement program and the agency’s lack of performance improvement projects. The Administrator stated Office Manager B was responsible. The Administrator stated he could email something to the surveyor tomorrow from his home computer. The surveyor asked the agency staff to identify any performance improvement projects the agency had documented. There was no response from the agency staff. The surveyor repeated the question. Office Manager B finally stated they were only copying The QAPI information from previous reports. The Administrator stated they should be doing them to improve services and the agency used to use a consultant to help with QAPI and since dropping accreditation in 2022 they did not. Agency policy review revealed a policy titled: “Performance Improvement Process: Data Collection revised 121108” which read in part: “Purpose -To collect data for priorities identified by Agency leaders…Policy – Agency will collect data to monitor performance of areas targeting for study and to determine effectiveness of change…” No agency policy was provided for Performance Improvement Projects.”

“Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This Element is not met as evidenced by: Based on interview, and record review, the agency failed to provide a patient and the patient’s or legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: patient conduct, patient responsibility, and patient rights in 3 (#1, #2, and #3) of 3 home visits completed by the nurse surveyor. Failure to provide written notice of patient rights and responsibilities meant patients may be unaware of their rights, responsibilities, and the process for filing grievances, which may impact their ability to participate in the provision of safe care and placed the clients at risk of receiving inadequate care. Record review of the sample home admission packet information requested on 03.05.2026 at 2pm revealed no printed version of the following required documents: Client Rights and Responsibilities and The Rights of the Elderly. Due the items being missing in the sample home admission packet, there is no date the items were made. Interview and record review on 03.10.2026 during the home visit of Patient 1 at 1pm, revealed that the there were no client “Rights and Responsibilities” nor “The Rights of the Elderly” documents in the home packet as required by agency policy. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 1 stated they had not removed anything and did not recall seeing a document about these rights. Interview and record review on 03.10.2026 during the home visit of Patient 2 at 11:30am, revealed there were no client “Rights and Responsibilities” nor “The Rights of the Elderly” documents in the home packet as required by agency policy. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 2 stated they had not removed anything and did not recall seeing a document about these rights. Interview and record review on 03.10.2026 during the home visit of Patient 3 at 10:00am, revealed there were no client “Rights and Responsibilities” nor “The Rights of the Elderly” documents in the home packet as required by agency policy. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 3 stated they had not removed anything and did not recall seeing a document about these rights. An interview was conducted with the Administrator and Director of Nursing on 3.11.2026 at 3:15pm regarding the home admission packet. The Administrator reported that the “copy people, our administrative staff makes the home packets in the office, and the numbers and rights should be in the home packet. I will make sure it will be there; we have it.” The Director of Nursing reported that the home packets are given to the admission nurses, and they go over the packets in the home prior to the initiation of care. She stated, “we have six home care [agencies] and they should all be there, the resource list and rights of the elderly.” Record review completed on 3.11.2026 at 3pm of the agency policy dated, 09.13.2011, titled, “Client Bill of Rights and Responsibilities: Rights of the Elderly” states, “The Agency will provide information regarding Client Bill of Rights and Client Responsibilities, Client Conduct, and The Rights of the Elderly (to persons age 60 and over) both verbally and in writing (in a manner that the client / guardian can understand) to each client or legal guardian in advance of furnishing care or during the initial evaluation visit before the initiation of treatment… agency will comply with the provisions of Human Resources Code, Chapter 102, concerning the rights of the elderly.” In the section titled, “Procedure”, B. “Agency staff will be responsible for knowing, observing, and implementing the client’s rights, client conduct, and client responsibilities on an ongoing basis… Section C. The Client Bill of Rights and Responsibilities and the Rights of the Elderly for those 60 years of age and older will be given to the client verbally and in writing at the time of the client’s assessment, prior to admission…””

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patients resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization for 3 of 3 patients (#1, #2, #3) who completed home visits with the nurse surveyor. This failure meant patients lacked information to ensure access to services as needed and to request an expedited review of changes in services provided by the agency. The agency did not follow policy to ensure the patients had the required numbers as required by regulation, placing clients at risk of receiving inadequate care. Review of the sample home admission packet information requested on 03.05.2026 at 2pm revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. Interview and record review on 03.10.2026 during home visit of Patient 1 at 1pm revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization In the home admission packet. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 1 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. Interview and record review on 03.10.2026 during home visit of Patient 2 at 11:30 am revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization In the home admission packet. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 2 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. Interview and record review on 03.10.2026 during home visit of Patient 3 at 10:00 am revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization In the home admission packet. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Patient 3 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. An interview was conducted with Registered Nurse A on 3.11.2026 at 12:02pm. Registered Nurse A stated that she reviewed everything in the home packets with the clients at the time of admission verbally and then has the patient sign the forms. She stated, “the packet is handed to me already put together by office staff. I just go through the list of stuff; I should have been more aware they [the resource telephone numbers] were not there.” An interview was conducted with the Administrator and Director of Nursing on 3.11.2026 at 3:15pm regarding the home admission packet. The Administrator reported that the “copy people, our administrative staff makes the home packets in the office, and the numbers and rights should be in the home packet. I will make sure it will be there; we have it.” The Director of Nursing reported that the home packets are given to the admission nurses, and they go over the packets in the home prior to the initiation of care. She stated, “we have six home care [agencies] and they should all be there, the resource list and rights of the elderly.” Record review of the agency policy dated, 09.13.2011, titled, “Resolution of Client Conflicts, Grievances or Complaints” Section C states, “The client Bill of Rights and Responsibilities and the Rights of the Elderly for those 60 years of age and older will be given to the client verbally and in writing at the time of the client’s assessment, prior to admission to the agency and prior to the initiation of care. Client will be informed of their right to make a complaint to the administrator of the Home Health agency and to the following: Department of Aging and Disability Services (DADS), Consumer Rights and Services Division… Toll Free 1-800-656-9656 24-hour hotline.” The telephone number is correct, but the policy is not updated to show the correct name: Texas Health and Human Services. Section D of policy states, “Once this agency is CHAP accredited, the client and/or family may contact CHAP regarding a complaint…” Record review of the agency policy dated, 09.13.2011, titled, “Client Bill of Rights and Responsibilities: Rights of the Elderly” Section C states, “The client Bill of Rights and Responsibilities and the Rights of the Elderly for those 60 years of age and older will be given to the client verbally and in writing at the time of the client’s assessment, prior to admission to the agency and prior to the initiation of care…” Section D states, “Prior to the start of care, agency will provide the client the toll-free Home Health Hotline… Client will receive in writing the telephone numbers for the state Home Health Hotline and the accreditation agency hotline…””