Abc Home Health

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview the home health agency failed to maintain compliance with this Condition of Participation to ensure each patient received a patient-specific initial assessment for whose records were reviewed, in that: The agency failed to confirm that an RN conducted the initial or subsequent comprehensive assessments to determine the immediate care and support need for Patient #1 and Patient #2. Refer G0514 The agency failed to ensure Patient #1’s and patient #2’s comprehensive assessment accurately included a review of all medications the patients used in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Refer G0536 Refer to G0514 Refer to G0536”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview the agency failed to maintain compliance with this Condition of Participation to ensure that 2 of 2 (Patient #1 and Patient #2) current patients’ records reviewed included plans of care for each patient that included all elements the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment and measurable outcomes that the agency anticipated would occur as a result of implementing and coordinating the plan of care in that: Patient #1’s and #2’s plan of care did not include the patient’s mental, psychosocial, and cognitive status, prognosis, rehabilitation potential, functional limitations, nutritional requirements, all medications and treatments, safety measures to protect against injury, description of the patient’s risk for emergency department visits and hospital re-admission and all necessary interventions to address the underlying risk factors, patient and caregiver education and training to facilitate timely discharge, information related to any advanced directives. G0574 Refer to G0574”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview the agency failed to confirm that an RN conducted the initial assessment to determine the immediate care and support needs for 2 of 2 patients (#1 and #2), whose clinical records were reviewed, in that: Patients #1 and #2 did not have an initial assessment in their clinical records. The failure of the agency not to include the initial assessments on the patients placed patients #1 and #2 at risk of not receiving an RN assessment to determine the patient’s immediate care and support needs. During presurvey record 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) on 08/11/26 revealed the agency’s license. The license showed the agency’s provider number, license number, type of services offered. The license had L&C as the service offered. The license was effective from 09/17/25 to 09/30/28. Review of agency policy titled “Initial Patient/Client Comprehensive Assessment,” last reviewed 013124, read in part , “ Purpose: to identify data collection needed on multiple aspects of the patient/client and the environment as a basis for individualized intervention and outcome- oriented care. Policy: Each patient/client will receive a patient/client comprehensive assessment… Procedure: II. The initial visit will be conducted within 48 hours of referral… IV. If nursing care is ordered an RN must complete the initial assessment, and for Medicare patients/clients determine eligibility for Medicare home health benefit, including homebound status….” Clinical record reviewed of Patient #1’s POC for certification period 04/17/26- 10/13/26 with SOC date of 04/17/26. Further review of the POC revealed diagnosis of essential primary hypertension. Continued review of the clinical record revealed that there was no initial assessment in Patient #1’s record. Clinical record reviewed of Patient #2’s POC for certification period 06/13/26- 12/09/26 with SOC date of 07/16/26. Further review of the POC revealed diagnosis of essential primary hypertension. Continued review of the clinical record revealed that there was no initial assessment in Patient #2’s record. During interview conducted on 08/12/26 with Adm during entrance conference at 10:00 a.m., the Adm said the agency only did telehealth monitoring for blood pressure on patients. The Adm said no home visits were made and said the agency had no skilled patients. During continued interview on 08/12/26 with Adm at 11:10 a.m. the Adm said she had 2 patients listed under the agency for Texas Medicaid Health Program(a joint federal and state program that provides medical and health coverage to low-income children, pregnant women, families, seniors, and people with disabilities in Texas), but they were not skilled patients. The Adm said under TMHP she could provide services to any age group of patients. During continued interview conducted on 08/13/26 with Adm at 1:19 p.m., the Adm said when the patient first comes on service with the agency the agency went out to the home to deliver the device and onboard the patient. When asked who delivered the equipment to the home and onboarded the patient the Adm said a family member of the Adm who did not work for the agency. The Adm said no skilled personnel went out to the home. The skilled personnel monitored the blood pressure and heart rate and if the numbers were all over the parameters set for the patient the skilled personnel called the patient and reported to the physician by phone. When asked who communicated with the doctor and patients the Adm said RN B communicated with the patient and the doctor by phone. On 08/13/26 at approximately 1:45 p.m. a phone call was attempted to Patient #1. There was no answer from Patient #1 to the phone call. On 08/13/26 at approximately 1:50 p.m. a phone call was attempted to Patient #2. A worker at the group home where the patient lived said Patient #2 was at a day program. The surveyor then called cell number listed on the POC for Patient #2. There was no answer to the phone call. During interview conducted on 08/13/26 with RN B at 2:00 p.m. the surveyor asked RN B what her role was with the agency. RN B said she had been with the agency for 3 years and said her role with the agency was to call and check on patients and educate them on their rights, telemonitoring program, and monitor blood pressure readings. When asked if she went to the patients’ home, RN B said no skilled nursing visit were done in person. RN B said she communicated with doctor and patients over the phone only for telemonitoring services.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately included a review of all medications the patient used for 2 of 2 patients (#1 and #2) whose clinical records were reviewed in that: Patient #1’s and #2’s clinical record did not include a list of medications or acknowledge that medications were reviewed. The failure placed Patient #1 and #2 at risk for potential adverse drug effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Clinical record reviewed of Patient #1’s POC for certification period 04/17/26- 10/13/26 with SOC date of 04/17/26. Further review of the POC revealed diagnosis of essential primary hypertension. The clinical record did not include an initial or comprehensive assessment that accurately listed any medications for Patient #1. Continued review of the clinical record revealed that there was no initial or comprehensive assessments in Patient #1’s record. Clinical record reviewed of Patient #2’s POC for certification period 06/13/26- 12/09/26 with SOC date of 07/16/26. Further review of the POC revealed diagnosis of essential primary hypertension. The clinical record did not include an initial or comprehensive assessment that accurately listed any medications for Patient #2. Continued review of the clinical record revealed that there was no initial or comprehensive assessment in Patient #2’s record. During interview conducted on 08/12/26 with Adm during the entrance conference at 10:00 a.m., the Adm said the agency only did telehealth monitoring for blood pressure on patients. The Adm said no home visits were made and said the agency had no skilled patients. During continued interview on 08/12/26 with Adm at 11:10 a.m. the Adm said she had 2 patients listed under the agency for Texas Medicaid Health Program(a joint federal and state program that provides medical and health coverage to low-income children, pregnant women, families, seniors, and people with disabilities in Texas), but they were not skilled patients. During continued interview on 08/12/26 with Adm at 1:00 p.m., the Adm said the agency was small and they were not doing skilled services. The Adm said when she and a partner became owners of the agency about 3 years ago the partner was doing the skilled services side for the agency and setting up everything. The Adm said she did not know that she needed skilled patients and needed to follow the policies for skilled services. The Adm said the partner she bought the agency with had since left and she now was the only owner. The Adm said she really did not know much about skilled services. During continued interview conducted on 08/13/26 with Adm at 1:19 p.m., the Adm said no skilled personnel went out to the patients’ homes. The skilled personnel monitored the blood pressure and heart rate readings and if the numbers were all over the parameters set for the patient the skilled personnel called the patient and reported to the physician by phone. When asked who communicated with the doctor and patients the Adm said RN A oversaw the whole clinical side of things for the agency and RN B communicated with the patient and the doctor by phone. On 08/13/26 at approximately 1:45 p.m. a phone call was attempted to Patient #1. There was no answer to the phone call. On 08/13/26 at approximately 1:50 p.m. a phone call was attempted to Patient #2. A worker at the group home where client lived said Patient #2 was at a day program. The surveyor then called cell number listed on the POC for Patient #2. There was no answer to the phone call. During interview conducted on 08/13/26 with RN B at 2:00 p.m. the surveyor asked RN B what her role was with the agency. RN B said she had been with the agency for 3 years and said her role with the agency was to call and check on patients and educate them on their rights, telemonitoring program, and monitor blood pressure readings. When asked if she went to the patients’ home, RN B said no skilled nursing visit were done in person. RN B said she communicated with the doctor and patients over the phone only for telemonitoring services. Review of agency policy titled “Initial Patient/Client Comprehensive Assessment,” last reviewed 013124, read in part , “ Purpose: to identify data collection needed on multiple aspects of the patient/client and the environment as a basis for individualized intervention and outcome- oriented care. Procedure VI. E. A review of all medications the patient/client is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure that 2 of 2 (Patient #1 and Patient #2) current patients’ plan of care included all required elements in that: Patient #1’s and Patient #2’s plans of care did not include the patient’s mental, psychosocial, and cognitive status, prognosis, rehabilitation potential, functional limitations, nutritional requirements, all medications and treatments, safety measures to protect against injury, description of the patient’s risk for emergency department visits and hospital re-admission and all necessary interventions to address the underlying risk factors, patient and caregiver education and training to facilitate timely discharge, information related to any advanced directives. The failure of Patient #1’s and Patient #2’s plan of care to not include all elements required placed Patient #1, and #2 at risk of not having all of their needs assessed to prevent hospitalization and their advance directives addressed. Review of agency policy titled “Plan of Care” last reviewed 031723, read in part, “Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems… Procedure: III. Each patient/client must receive an individualized written plan of care… The individualized plan of care will indicate if the patient/client has an advanced directive(s)…if the patient does not have an advanced directive , this should also be listed on the individualized plan of care… A. The individualized plan of care must include the following: 1. All pertinent diagnosis; 2. The patient’s/client’s mental, psychosocial, and cognitive status; 3. The types of services, supplies, and equipment required; 4. The frequency and duration of visits to be made; 5. Prognosis; 6. Rehabilitation potential; 7. Functional limitations; 8. Activities permitted; 9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury; 12. A description of the patient’s/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors…” Clinical record reviewed of Patient #1’s POC for certification period 04/17/26- 10/13/26 with SOC date of 04/17/26. The POC titled, RPM(remote patient monitoring)/Telemonitoring Care Plan,” revealed diagnosis of essential primary hypertension. The POC had Patient #1 date of birth, certification period, doctor’s name and phone number. It listed RN B as Case Manager. Continued review of POC had a place for medications with no medications listed. Vital sign parameters listed as follows: Systolic blood pressure 95 as lower limit and 145 as upper limit; diastolic blood pressure 55 as lower limit and 90 as upper limit; heart rate 50 as lower limit and 110 as upper limit. The POC had supplies listed as blood pressure monitor, adult large blood pressure cuff and 4 AA batteries. The POC had orders for agency to 1. Enroll patient in telemonitoring services. Telemonitoring staff members would report vital signs out of parameters to physician. 2. Telemonitoring staff member would instruct Client/CG on proper use of Telemonitoring equipment. 3. Telemonitoring staff member will instruct Client/CG on emergency preparedness(211) and emergent situation that would necessitate calling 911. 4. Telemonitoring staff member will instruct Client/CG on availability of telemonitoring service including 24/7 call and phone number to dial for non-emergent situation. 5. Hold Telemonitoring services if Client was admitted to inpatient facility and resume services upon inpatient discharge. 6. Telemonitoring services will be discontinued at Client/physician request. Continued review of the POC listed goals for Patient #1 for BP to be maintained within the acceptable range as determined by physician through review date. The interventions listed was for the agency to monitor vital signs as ordered, record, and report significant abnormalities to the physician. The POC was signed and dated by RN B and physician on 04/16/26. Further review of the POC revealed that the POC for Patient #1 did not include documentation of the patient’s mental, psychosocial, and cognitive status, prognosis, rehabilitation potential, functional limitations, nutritional requirements, all medications and treatments, safety measures, description of the patient’s risk for emergency department visits and hospital re-admission, patient and caregiver education and training to facilitate timely discharge, information related to any advanced directives, and all necessary interventions to address the underlying risk factors. Clinical record reviewed of Patient #2’s POC for certification period 06/13/26- 12/09/26 with SOC date of 07/16/26. The POC titled, RPM(remote patient monitoring)/Telemonitoring Care Plan,” revealed diagnosis of essential primary hypertension. The POC had Patient #2 date of birth, and certification period. Continued review of POC had a place for medications with no medications listed. Vital sign parameter listed as Systolic blood pressure 100 as lower limit and 160 as upper limit; diastolic blood pressure 70 as lower limit and 100 as upper limit; heart rate 60 as lower limit and 100 as upper limit. The POC had supplies listed as blood pressure monitor, adult large blood pressure cuff and 4 AA batteries. The POC had orders for agency to 1. Enroll patient in telemonitoring services. Telemonitoring staff members would report vital signs out of parameters to physician. 2.Telemonitoring staff member would instruct Client/CG on proper use of Telemonitoring equipment. 3.Telemonitoring staff member will instruct Client/CG on emergency preparedness(211) and emergent situation that would necessitate calling 911. 4. Telemonitoring staff member will instruct Client/CG on availability of telemonitoring service including 24/7 call and phone number to dial for non-emergent situation. 5. Hold Telemonitoring services if Client was admitted to inpatient facility and resume services upon inpatient discharge. 6. Telemonitoring services will be discontinued at Client/physician request. Continued review of the POC listed goals for Patient #2 that blood pressure would remain within normal limits and prevent hospitalization. Monitor vital signs as ordered and record and to report significant abnormalities to the physician. The POC was signed and dated by RN B and physician on 05/21/26. Further review of Patient #2’s POC revealed that the POC did not include documentation of the patient’s mental, psychosocial, and cognitive status, prognosis, rehabilitation potential, functional limitations, nutritional requirements, all medications and treatments, safety measures, description of the patient’s risk for emergency department visits and hospital re-admission, patient and caregiver education and training to facilitate timely discharge, information related to any advanced directives, and all necessary interventions to address the underlying risk factors. During interview conducted on 08/12/26 with Adm during entrance conference at 10:00 a.m., the Adm said the agency only does telehealth monitoring for blood pressure on patients. The Adm said no home visits were made and said the agency had no skilled patients. The Adm said Medicare was supposed to come do a walkthrough for palmetto (government contractor for Medicare) to make sure everything was okay with services and that was who the Adm thought the surveyor was. During continued interview on 08/12/26 with Adm at 11:10 a.m. the Adm said she had 2 patients listed under the agency for Texas Medicaid Health Program(a joint federal and state program that provides medical and health coverage to low-income children, pregnant women, families, seniors, and people with disabilities in Texas), but they were not skilled patients. The Adm said under TMHP she could provide services to any age group of patients. The Adm said she had no staff, just the Adm, Alt Adm, RN A who was the Director of Nursing, and RN B who acted as the clinical manager. The Adm said RN A and RN B did not offer skilled services for the agency, only telemonitoring services. When asked who was over her skilled services for the L&C category the agency had on the license, the Adm said when she and a partner became the new owners her partner was, but he left so she really did not focus on the skilled services only telemonitoring services. During continued interview on 08/12/26 with Adm at 1:00 p.m., the surveyor asked who was over the skilled services for the L&C category the agency had on the license. The Adm said the agency was small and they were not doing skilled services. The Adm said when she and a partner became owners of the agency about 3 years ago the partner was doing the skilled services side for the agency and setting up everything. The Adm said she did not know that she needed skilled patients and needed to follow the policies for skilled services. The Adm said the partner she bought the agency with has since left and she now is the only owner. The Adm said she really did not know much about skilled services. On 08/13/26 at approximately 1:45 p.m. a phone call was attempted to Patient #1. There was no answer from Patient #1 to phone call. On 08/13/26 at approximately 1:50 p.m. a phone call was attempted to Patient #2. A worker at the group home where patient lived said Patient #2 was at day program. The surveyor then called cell number listed on the POC for Patient #2. There was no answer to the phone call. During interview conducted on 08/13/26 with RN B at 2:00 p.m. the surveyor asked RN B what her role was with the agency. RN B said she had been with the agency for 3 years and said her role with the agency was to call and check on patients and educate them on their rights, the telemonitoring program, and monitor blood pressure readings. When asked if she went to the patients’ home, RN B said no skilled nursing visit were done in person. RN B said she communicated with doctor and patients over the phone only for telemonitoring services.”