Superior Home Health of San Antonio LLC

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to enforce its written policy to make sure patient services were integrated among all services including all agency personnel to ensure optimal patient outcomes in 1 of 8 patients reviewed. (#10) This failure could affect the agency’s active patients who receive care and could delay services provided preventing optimal care. The findings included: Observation on 8/20/2025 at 1:00 pm, during a home visit with Patient #10 revealed RN (Employee C) completing a recertification for patient #10 where the Surveyor heard RN (Employee C) state “I am sorry for the confusion and you not receiving your physical therapy visits, there was a scheduling error”. Record review of Patient #10’s Physical Therapy Plan of Care with Partial Evaluation (certification period 6/26/2025-8/24/2025) revealed SOC 6/26/2025 with a diagnosis of weakness. Further review revealed in part “Discipline Orders and Treatment Frequency: 2w4” Record review of policy with a last reviewed date of 050124 and titled “Monitoring Patient/Client Care/Coordination of Care” stated in part “…I. The Agency will:….C. Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines…”. During an interview on 8/20/2025 at 1:40 p.m., with Patient #10 revealed he had not received any visits for therapy “only the first one when I first started but then no visits after that.” Stated a letter was received from insurance notifying approval for therapy visits 2 times a week for 4 weeks but did not have the letter available. He reported he did not notify any agency staff that he had not received his visits. During an interview on 8/21/2025 at 10:47 a.m., with Supervising Nurse (Employee B) Stated she was unaware of the incident until 8/14/2025 when the Physical Therapist completed her re-evaluation this is when an audited was completed and noted that the visits were not scheduled. Supervising Nurse (Employee B) went on to say she did not know why the visit were not scheduled and there was no communication note to address why the visits were not made. During an interview on 8/21/2025 at 11:54 a.m., with LVN (Employee F) stated that these visits were not schedule due to no communication from the Physical Therapist after the evaluation was completed. Employee F went on to say that they use a messenger application on their phones to communicate frequency and after review stated the frequency was not reported and the visits were not plotted. During an interview on 8/21/2025 at 1:03 p.m., with Scheduler (Employee E) stated that the patient missed visits were due to miscommunication and they are still learning the new Electronic Medical Record system. During an interview on 8/22/2025 at 10:01 a.m., with Physical Therapist (PT) (Employee G) stated a Physical Therapy Re-evaluation was scheduled for her on 8/14/2025 and that is when she noted the patient’s physical therapy visits had not been completed due not being scheduled. PT (Employee G) went on to say after the first evaluation on 7/10/2025 of Patient #10, the office was contacted via phone messenger application to notify of frequency on 7/10/2025 and does not know why the visits did not get assigned to the physical therapy assistant, went on to say it is the scheduler’s responsibility to plot the visits. No additional information was provided by the agency at time of exit on 8/22/2025 or within two business days.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure compliance that the standard contents of clinical record by not sending the discharge summary to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA within five (5) business days of the date of the order for discharge from the responsible physician for 4 of 4 patients reviewed. (#3, #4, #11 and #12)\ This failure can place the patients at risk of not having a proper care after discharge and could affect the agency’s other 82 patients receiving licensed home health services. The findings included: Review of the agency’s policy titled “Medical Record Content” revealed in part, “....Last Reviewed; 070524…9. A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient/client after discharge from the Agency (if any) within five business days of the patient’s/client’s discharge; or….”. Closed record review of Patient’s #3, #4, #11 and #12’s clinical records revealed that they had been discharged from the agency but the records failed to contain documentation that the discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA. During an interview on 8/21/2025 at 11:54 a.m. with the Scheduler (Employee F) findings above were reviewed, Employee revealed that she did not send the discharge summaries to the physician and that is the job of LVN (Employee E). During an interview on 8/21/2025 at 1:03 p.m. with the LVN (Employee E), the findings above were reviewed who revealed he did not send the discharge summaries were not sent to the physician, that was the job of Scheduler (Employee F). During an interview on 8/21/2025 at 4:45 p.m. with the Alt Adm (Employee A) the findings above were reviewed and discussed and revealed that after reviewing with LVN (Employee E) and Scheduler (Employed F), noted discharge summaries were not sent for Patient’s #3, #4, #11 and #12’s. Stated he did not know why, and he would investigate. No additional information was provided by the agency at time of exit on 8/22/2025 or within two business days.”