Reliant Healthcare Services

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide the proper written Notice of Medicare Non-Coverage no later than two days in advance of terminating on-going care that included the correct QIO telephone number and the patient or representative signature in two of two discharge records reviewed whose reason for discharge was goals met (Patient 3 and 4). This failure had the potential to result in patients being unable to contact the QIO in the event they chose to exercise their right to appeal the discharge decision. This failure failed to protect the rights of the patients and to ensure the implementation of agency policy and procedures related to the discharge of agency patients. Findings included: Regulation: July 1, 2005, the Medicare regulations (Benefits Improvement and Protection Act) BIPA gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary’s Medicare coverage of services is ending. The phone number for the QIO should be included in this notice (888-315-0636). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. A patient discharge list with discharge reason was provided to the surveyor by the Adm on 02/06/2025. During an interview with the Adm at the entrance conference on 02/06/2025 at 12:45 PM, the Adm stated he was responsible for ensuring correct information was included on the discharge notice titled, “Notice of Medicare Non-Coverage.” Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024. The discharge list included Patient 3’s discharge date was 12/04/2024 with a discharge reason of goals met. Record review of the clinical record contained the Centers for Medicare and Medicaid Services form titled, “Notice of Medicare Non-Coverage.” The form read in part, “ ...The effective date coverage of your Current Home Health Services Will End: ... 12/04/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…” The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 3 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 3 or representative should have signed the form to indicate an understanding of the notice. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The discharge list included Patient 4’s discharge date was 08/02/2024 with a discharge reason of goals met. The clinical record contained the Centers for Medicare and Medicaid Services form titled, “Notice of Medicare Non-Coverage.” The form read in part, “ ...The effective date coverage of your Current Home Health Services Will End: ... 08/02/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…” The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 4 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 4 or representative should have signed the form to indicate an understanding of the notice. During an interview with the DON on 02/14/2025 at 11:26 AM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The DON stated she usually had the patients sign the notice when she made the discharge visit, but that was not the case with Patients 3 and 4. The DON stated when licensed vocational nurses conducted visits during the episode, the licensed vocational nurses needed to give the notice. The DON stated she did not know the QIO’s phone number had changed. The DON stated the Adm was responsible for ensuring the correct information was included on the Notice of Medicare Non-Coverage form. The surveyor asked why areas of non-compliance were not identified and included in quality assurance activities and why agency policies were not followed. The DON stated they must have missed the issues and would try to go through everything to ensure the agency was in compliance. The DON further stated she would be more diligent going forward. During an interview with the Adm on 02/14/2025 at 3:00 PM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The Adm stated he did not have an answer and that it had been overlooked. The Adm stated he was unaware of the issues. During a telephone interview with the Adm on 02/14/2025 at 3:16 pm, the Adm stated agency polices were not followed because they were things the agency overlooked. Agency policy titled, “Policy 4.20: DISCHARGE/TRANSFER/REFERRAL OF PATIENTS” undated, read in part, “… PURPOSE… To uphold the patient’s right to receive information about his/her care, treatment and services and to be involved in the decision-making process when appropriate… POLICY… Any discharge, transfer or referral of patients shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and in such a way as to prevent harm to the patient… The patient/family shall be an active participant, when possible, in planning his/her referral, transfer and/or discharge…” Agency policy titled, “Policy 4.21: CRITERIA FOR DISCHARGE - TRANSFER/DISCHARGE SUMMARY” undated, read in part, “… PURPOSE: To ensure a standardized process for discharging patients… To uphold the patient’s right to receive information about his/her care, treatment and/or services and to be involved in the decision-making process when appropriate… POLICY: Any discontinuation of care, treatment and/or services should be done in an appropriate manner and in such a way as to prevent harm to the patient… The patient should be an active participant, when possible, in planning his/her referral, transfer and/or discharge…””

“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: This is a continuing deficiency from the survey dated 02/25/2022 cited at G0574. Based on record review and interview, the agency failed to ensure the plan of care included all pertinent diagnoses; the frequency of visits to be made; safety measures to protect against injury and patient-specific interventions in four of ten records reviewed (Patient 1, 2, 3, and 4) in that: a. In one of ten records reviewed (Patient 1), the plan of care did not include a diagnosis for an implantable infusion port (a central line implanted under the skin used for medication administration) and dialysis shunt (also known as a graft or fistula; A surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body); the type and location of the implantable infusion port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit (a rumbling sound that you can hear with a stethoscope over the area of a dialysis shunt) and thrill (vibration on the skin over the area of a dialysis shunt). b. In one of ten records reviewed (Patient 2), the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. c. In one of ten records reviewed (Patient 3), the plan of care did not include bleeding precautions and safety measures for a blood thinner medication. d. In one of ten records reviewed (Patient 4), the plan of care did not include the frequency of nursing visits. These failures placed patients at risk of harm from agency staff who could not address the patient’s risk factors and type of services needed for appropriate care, placing patients at risk of declining health status and the potential for hospitalizations and long-term care facility placement. Findings included: According to Nursing2025 Protecting a Hemodialysis Fistula https://journals.lww.com/nursing/citation/2002/11000/protecting_a_hemodialysis_fistula.8.aspx November 18, 2002. Feel for a thrill (vibration on the skin over the area of turbulent blood flow) by touching the fistula and listen for a bruit (a rumbling sound that you can hear with a stethoscope). Assess the fistula for signs and symptoms of infection. Don’t take blood pressures on the access arm as it can contribute to infection and clotting in the fistula. According to https://www.inogen.com/blog/10-home-oxygen-safety-tips/ February 8, 2021. Home oxygen safety is one of the most important aspects of oxygen therapy. Although oxygen is a safe, non-flammable gas, it does support combustion, meaning things burn more readily and ignite easier in its presence. As such, you must be careful to follow oxygen safety in the home, and to make sure anyone in your home is aware of oxygen tank safety. According to WebMD https://www.webmd.com/dvt/blood-thinner-tips January 22, 2025. bleeding safety precautions while taking a blood thinner include: Take good care when you exercise or are active. Even a minor cut may bleed a lot if you’re on these medications. Wear gloves when you use sharp objects like scissors, knives, and gardening tools. Switch to an electric razor. You’re less likely to nick your skin. Wear sturdy shoes as often as possible -- always when you mow the lawn or garden. Use a soft toothbrush and waxed dental floss to clean your teeth. They’re easier on your gums. During the entrance conference with the Adm on 02/06/2025 at 12:45 pm, the Adm stated he was responsible for ensuring the plan of cares included required elements. Patient 1: Record review of the medical record included a plan of care dated 11/20/2024 to 01/18/2025 signed by the DON on 11/18/2024. The plan of care included a diagnosis of high blood pressure with chronic kidney disease and dependence on dialysis with a nursing visit frequency of once weekly for nine weeks. The plan of care read in part, “…assess permacath (a special IV device/catheter inserted in a blood vessel for the administration of medications (infusion port) or a dialysis shunt/graft/fistula)site every visit and prn including signs and symptoms of infection to site…” The plan of care did not indicate what the permacath was; what it was used for; or where it was located. The plan of care did not include a diagnosis for an implantable infusion port (a central line implanted under the skin used for medication administration) and dialysis shunt; the type or location of the implantable infusion port site; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit and thrill. The record included a recertification nursing assessment signed and dated by the DON on 11/18/2024 that included the patient had a dialysis shunt/graft/fistula. The assessment did not include where the shunt/graft/fistula was located. The record included a house call visit note signed and dated by NP on 10/30/2024 that read in part, “… reports a recent diagnosis of rectal cancer diagnosed in 2023 and underwent surgery, chemo….” The record included a nursing visit note signed and dated by LVN A on 11/22/2024 that read in part, “… hemodialysis… has a port to his right upper chest he used before for chemo…” During an interview with the DON on 02/14/2025 at 10:54 am, the DON stated she was responsible for ensuring the patient’s plan of care included all required elements and she tried to review the plan of cares before signing them but did not review them all the time. The DON stated she needed to do better. The DON further stated the patient had a dialysis catheter and a chemo port. The DON stated the permacath was the dialysis shunt where the patient received dialysis treatments. The surveyor asked why the plan of care did not include a diagnosis for an implantable infusion port and dialysis shunt; the type and location of the implantable infusion/chemo port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt; safety measures for the dialysis shunt and for the nurse to assess the dialysis shunt for a bruit and thrill. The DON stated she tried to put all the information on the plan of care but she did not think the plan of care was populating and pulling the information from the recertification assessment like it was supposed to. The DON stated she reviewed the plan of care and the 11/18/2024 assessment but the information was not included. The DON stated the plan of care did include orders to assess for signs and symptoms of infection, but the order was not specific and she needed to do better. Patient 2: Record review of the medical record included a plan of care dated 12/02/2024 to 01/30/2025 signed by the DON on 11/27/2024 and included a diagnosis of dependence on oxygen and a blood thinning medication, Clopidogrel, to be taken once daily. The plan of care included a nursing visit frequency of once weekly for nine weeks. The plan of care did not include oxygen safety measures; bleeding precautions and safety measures for the blood thinner medication. The record included a medical doctor visit note dated 12/04/2024 and signed by MD on 12/05/2024 that included the patient was on a blood thinning medication, Clopidogrel, and continuous oxygen. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor asked why the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. The DON stated she missed adding the information to the plan of care. Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024 and included the medication, Eliquis (blood thinner) to be taken twice daily. The plan of care included a diagnosis of long term use of a blood thinner and a nursing visit frequency of once weekly for nine weeks. The plan of care did not include bleeding precautions and safety measures for the blood thinner medication. During an interview with the DON on 02/14/2025 at 11:18 am, the surveyor asked why the plan of care did not include bleeding precautions and safety measures for the blood thinner medication. The DON stated she missed including the information on the plan of care. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The plan of care included a diagnosis of arthritis and high blood pressure. The plan of care did not include the frequency of nursing visits. During an interview with the DON on 02/14/2025 at 11:22 am, the surveyor asked why the plan of care did not include the frequency of nursing visits. The DON stated she missed including the information on the plan of care, but it should have been included. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The DON stated they tried including everything on the plan of cares, but they really needed to work on the issue. During a telephone interview with the Adm on 02/14/2025 at 3:04 pm, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The Adm stated he believed the agency corrected the problem but it seemed the issues were still occurring. The Adm further stated after the 2022 survey, the agency staff talked as a team about the plan of cares and everybody agreed on what should be done. During a telephone interview with the Adm on 02/14/2025 at 3:16 pm, the Adm stated agency policies were not followed because they were things the agency overlooked. Agency policy titled “Policy 4.16: Care Planning” undated, read in part, “PURPOSE: To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes. POLICY: The plan of care is developed and documented by the Registered Nurse… PROCEDURE: Each discipline, i.e., nursing, therapies, social work, including contracted services, develops a plan of care based on the assessment of patient needs and clinical status at the time of the initial/ admission visit… The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient’s needs and clinical status, and promotes positive outcomes and avoids duplication of services… Each member of the healthcare team reviews the plan of care at least every two (2) weeks and more often if necessary, based on patient needs and clinical status to evaluate the appropriateness of the plan and the patient’s progress toward goals… The healthcare team member updates the plan of care as necessary…” Agency policy titled “Policy 4.9: Assessment” undated, read in part, “PURPOSE To identify the patient’s needs for care, treatment and/or services within an appropriate time frame based on the patient’s needs and complexity of treatment. To determine the appropriate care, treatment and/or services to meet the patient’s initial needs, as well as his/her changing needs… To ensure that the patient’s current needs and/or problems are continuously evaluated and the care, treatment and/or services provided are adjusted accordingly… Data obtained during assessment visits is used to determine the patient’s needs for care, treatment and/or services and to develop a plan of care… A proposed plan of care, based upon assessment findings, is developed and discussed with the patient and/or significant other… The comprehensive assessment is updated and revised by the appropriate skilled professional: To ensure that the plan of care is appropriately individualized to meet the patient’s needs… The Comprehensive Assessment… Includes the following information… The patient’s problems, needs… Pertinent diagnoses… A proposed plan of care/clinical pathway is developed and discussed with the patient/family/significant other… The completed plan of care is submitted to the Director of Patient Care Services/Intake Coordinator/ Clinical Supervisor/Performance Improvement Department within 24 hours of receipt of the information in the Data Entry Department for review as to accuracy and completeness…””

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record review and interview, the Adm failed to carry out, organize and direct the agency’s ongoing functions in that: 1. The Adm failed to provide oversight to ensure the plan of care included all pertinent diagnoses; the frequency of visits to be made; safety measures to protect against injury and patient-specific interventions in four of ten records reviewed (Patient 1, 2, 3, and 4) in that: a. In one of ten records reviewed (Patient 1), the plan of care did not include a diagnosis for an implantable infusion port (a central line implanted under the skin used for medication administration) and dialysis shunt (also known as a graft or fistula; A surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body); the type and location of the implantable infusion port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit a rumbling sound that you can hear with a stethoscope over the area of a dialysis shunt and thrill (vibration on the skin over the area of a dialysis shunt). b. In one of ten records reviewed (Patient 2), the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. c. In one of ten records reviewed (Patient 3), the plan of care did not include bleeding precautions and safety measures for a blood thinner medication. d. In one of ten records reviewed (Patient 4), the plan of care did not include the frequency of nursing visits. 2. The Adm failed to ensure the written Notice of Medicare Non-Coverage included the correct QIO telephone number and the patient or representative signature in two of two discharge records reviewed whose reason for discharge was goals met (Patient 3 and 4). 3. The agency’s Adm and Alt Adm failed to complete 12 hours of continuing education in the required topics within each 12 months in that job as required for the position of the Adm and Alt Adm of an agency in two of two records reviewed for continuing education requirements (Adm and Alt Adm). These failures showed lack of overall administrative leadership, ineffective or improper management of the agency’s operations and oversight that could negatively impact and protect the rights and safety of agency patients and staff. Findings included: 1. According to Nursing2025 Protecting a Hemodialysis Fistula https://journals.lww.com/nursing/citation/2002/11000/protecting_a_hemodialysis_fistula.8.aspx November 18, 2002. Feel for a thrill by touching the fistula and listen for a bruit. Assess the fistula for signs and symptoms of infection. Don’t take blood pressures on the access arm as it can contribute to infection and clotting in the fistula. According to https://www.inogen.com/blog/10-home-oxygen-safety-tips/ February 8, 2021. Home oxygen safety is one of the most important aspects of oxygen therapy. Although oxygen is a safe, non-flammable gas, it does support combustion, meaning things burn more readily and ignite easier in its presence. As such, you must be careful to follow oxygen safety in the home, and to make sure anyone in your home is aware of oxygen tank safety. According to WebMD https://www.webmd.com/dvt/blood-thinner-tips January 22, 2025. bleeding safety precautions while taking a blood thinner include: Take good care when you exercise or are active. Even a minor cut may bleed a lot if you’re on these medications. Wear gloves when you use sharp objects like scissors, knives, and gardening tools. Switch to an electric razor. You’re less likely to nick your skin. Wear sturdy shoes as often as possible -- always when you mow the lawn or garden. Use a soft toothbrush and waxed dental floss to clean your teeth. They’re easier on your gums.During the entrance conference with the Adm on 02/06/2025 at 12:45 pm, the Adm stated the DON was responsible for ensuring the plan of cares included required elements. Patient 1: Record review of the medical record included a plan of care dated 11/20/2024 to 01/18/2025 signed by the DON on 11/18/2024. The plan of care included a diagnosis of high blood pressure with chronic kidney disease and dependance on dialysis with a nursing visit frequency of once weekly for nine weeks. The plan of care read in part, “…assess permacath (a special IV device/catheter inserted in a blood vessel for the administration of medications (infusion port) or a dialysis shunt/graft/fistula) site every visit and prn including signs and symptoms of infection to site…” The plan of care did not indicate what the permacath was; what it was used for; or where it was located. The plan of care did not include a diagnosis for an implantable infusion port and dialysis shunt; the type or location of the implantable infusion port site; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt and implantable infusion port; and for the nurse to assess the dialysis shunt for a bruit and thrill. The record included a recertification nursing assessment signed and dated by the DON on 11/18/2024 that included the patient had a dialysis shunt/graft/fistula. The assessment did not include where the shunt/graft/fistula was located. The record included a house call visit note signed and dated by NP on 10/30/2024 that read in part, “… reports a recent diagnosis of rectal cancer diagnosed in 2023 and underwent surgery, chemo….” The record included a nursing visit note signed and dated by LVN A on 11/22/2024 that read in part, “… hemodialysis… has a port to his right upper chest he used before for chemo…” During an interview with the DON on 02/14/2025 at 10:54 am, the DON stated she was responsible for ensuring the patient’s plan of care included all required elements and she tried to review the plan of cares before signing them but did not review them all the time. The DON stated she needed to do better. The DON further stated the patient had a dialysis catheter and a chemo port. The DON stated the permacath was the dialysis shunt where the patient received dialysis treatments. The surveyor asked why the plan of care did not include a diagnosis for an implantable infusion port and dialysis shunt; the type and location of the implantable infusion/chemo port; orders for the nurse to assess the implantable infusion port for signs and symptoms of infection; the type and location of the dialysis shunt; safety measures for the dialysis shunt; safety measures for the dialysis shunt and for the nurse to assess the dialysis shunt for a bruit and thrill. The DON stated she tried to put all the information on the plan of care but she did not think the plan of care was populating and pulling the information from the recertification assessment like it was supposed to. The DON stated she reviewed the plan of care and the 11/18/2024 assessment but the information was not included. The DON stated the plan of care did include orders to assess for signs and symptoms of infection, but the order was not specific and she needed to do better. Patient 2: Record review of the medical record included a plan of care dated 12/02/2024 to 01/30/2025 signed by the DON on 11/27/2024 and included a diagnosis of dependence on oxygen and a blood thinning medication, Clopidogrel, to be taken once daily. The plan of care included a nursing visit frequency of once weekly for nine weeks. The plan of care did not include oxygen safety measures; bleeding precautions and safety measures for the blood thinner medication. The record included a medical doctor visit note dated 12/04/2024 and signed by MD on 12/05/2024 that included the patient was on a blood thinning medication, Clopidogrel, and continuous oxygen. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor asked why the plan of care did not include oxygen safety measures; bleeding precautions and safety measures for a blood thinner medication. The DON stated she missed adding the information to the plan of care. Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024 and included the medication, Eliquis (blood thinner) to be taken twice daily. The plan of care included a diagnosis of long term use of a blood thinner and a nursing visit frequency of once weekly for nine weeks. The plan of care did not include bleeding precautions and safety measures for the blood thinner medication. During an interview with the DON on 02/14/2025 at 11:18 am, the surveyor asked why the plan of care did not include bleeding precautions and safety measures for the blood thinner medication. The DON stated she missed including the information on the plan of care. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The plan of care included a diagnosis of arthritis and high blood pressure. The plan of care did not include the frequency of nursing visits. During an interview with the DON on 02/14/2025 at 11:22 am, the surveyor asked why the plan of care did not include the frequency of nursing visits. The DON stated she missed including the information on the plan of care, but it should have been included. During an interview with the DON on 02/14/2025 at 11:35 am, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The DON stated they tried including everything on the plan of cares, but they really needed to work on the issue. During a telephone interview with the Adm on 02/14/2025 at 3:04 pm, the surveyor stated during the survey dated 02/25/2022, the agency was cited for not including all required elements on the plan of cares and the agency submitted a plan of correction to correct the deficient practice. The surveyor asked why the plan of correction was not followed and the deficient practice continued. The Adm stated he believed the agency corrected the problem but it seemed the issues were still occurring. The Adm further stated after the 2022 survey, the agency staff talked as a team about the plan of cares and everybody agreed on what should be done. Agency policy titled “Policy 4.16: Care Planning” undated, read in part, “PURPOSE: To facilitate appropriate coordination and continuity of care and to promote positive patient outcomes. POLICY: The plan of care is developed and documented by the Registered Nurse… PROCEDURE: Each discipline, i.e., nursing, therapies, social work, including contracted services, develops a plan of care based on the assessment of patient needs and clinical status at the time of the initial/ admission visit… The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient’s needs and clinical status, and promotes positive outcomes and avoids duplication of services… Each member of the healthcare team reviews the plan of care at least every two (2) weeks and more often if necessary, based on patient needs and clinical status to evaluate the appropriateness of the plan and the patient’s progress toward goals… The healthcare team member updates the plan of care as necessary…” Agency policy titled “Policy 4.9: Assessment” undated, read in part, “PURPOSE To identify the patient’s needs for care, treatment and/or services within an appropriate time frame based on the patient’s needs and complexity of treatment. To determine the appropriate care, treatment and/or services to meet the patient’s initial needs, as well as his/her changing needs… To ensure that the patient’s current needs and/or problems are continuously evaluated and the care, treatment and/or services provided are adjusted accordingly… Data obtained during assessment visits is used to determine the patient’s needs for care, treatment and/or services and to develop a plan of care… A proposed plan of care, based upon assessment findings, is developed and discussed with the patient and/or significant other… The comprehensive assessment is updated and revised by the appropriate skilled professional: To ensure that the plan of care is appropriately individualized to meet the patient’s needs… The Comprehensive Assessment… Includes the following information… The patient’s problems, needs… Pertinent diagnoses… A proposed plan of care/clinical pathway is developed and discussed with the patient/family/significant other… The completed plan of care is submitted to the Director of Patient Care Services/Intake Coordinator/ Clinical Supervisor/Performance Improvement Department within 24 hours of receipt of the information in the Data Entry Department for review as to accuracy and completeness…” Regulation: July 1, 2005, the Medicare regulations (Benefits Improvement and Protection Act) BIPA gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary’s Medicare coverage of services is ending. The phone number for the QIO should be included in this notice (888-315-0636). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. A patient discharge list with discharge reason was provided to the surveyor by the Adm on 02/06/2025. During an interview with the Adm at the entrance conference on 02/06/2025 at 12:45 PM, the Adm stated he was responsible for ensuring correct information was included on the discharge notice titled, “Notice of Medicare Non-Coverage.” Patient 3: Record review of the medical record included a plan of care dated 10/10/2024 to 12/08/2024 signed by the DON on 10/09/2024. The discharge list included Patient 3’s discharge date was 12/04/2024 with a discharge reason of goals met. The clinical record contained the Centers for Medicare and Medicaid Services form titled, “Notice of Medicare Non-Coverage.” The form read in part, “ ...The effective date coverage of your Current Home Health Services Will End: ... 12/04/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…” The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 3 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 3 or representative should have signed the form to indicate an understanding of the notice. Patient 4: Record review of the medical record included a plan of care dated 06/06/2024 to 08/04/2024 signed by the DON on 06/03/2024. The discharge list included Patient 4’s discharge date was 08/02/2024 with a discharge reason of goals met. The clinical record contained the Centers for Medicare and Medicaid Services form titled, “Notice of Medicare Non-Coverage.” The form read in part, “ ...The effective date coverage of your Current Home Health Services Will End: ... 08/02/24 ...Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above. You may have to pay for any services you receive after the above date…How to Ask for an Immediate Appeal…Call your QIO at: 844-430-9504 to appeal, or if you have questions… Please sign below to indicate you received and understood this notice…” The form was not signed by the patient or representative and included the incorrect QIO phone number 844-430-9504. Patient 4 should have received the notice to appeal the discharge decision that included the correct QIO phone number 888-315-0636. Patient 4 or representative should have signed the form to indicate an understanding of the notice. During an interview with the DON on 02/14/2025 at 11:26 AM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The DON stated she usually had the patients sign the notice when she made the discharge visit, but that was not the case with Patients 3 and 4. The DON stated when licensed vocational nurses conducted visits during the episode, the licensed vocational nurses needed to give the notice. The DON stated she did not know the QIO’s phone number had changed. The DON stated the Adm was responsible for ensuring the correct information was included on the Notice of Medicare Non-Coverage form. The surveyor asked why areas of non-compliance were not identified and included in quality assurance activities and why agency policies were not followed. The DON stated they must have missed the issues and would try to go through everything to ensure the agency was in compliance. During an interview with the Adm on 02/14/2025 at 3:00 PM, the surveyor asked why Patients 3 and 4 did not sign the Notice of Medicare Non-Coverage form and why the wrong QIO phone number was listed on the form. The Adm stated he did not have an answer and that it had been overlooked. The Adm stated he was unaware of the issues. Agency policy titled, “Policy 4.20: DISCHARGE/TRANSFER/REFERRAL OF PATIENTS” undated, read in part, “… PURPOSE… To uphold the patient’s right to receive information about his/her care, treatment and services and to be involved in the decision-making process when appropriate… POLICY… Any discharge, transfer or referral of patients shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and in such a way as to prevent harm to the patient… The patient/family shall be an active participant, when possible, in planning his/her referral, transfer and/or discharge…” Agency policy titled, “Policy 4.21: CRITERIA FOR DISCHARGE - TRANSFER/DISCHARGE SUMMARY” undated, read in part, “… PURPOSE: To ensure a standardized process for discharging patients… To uphold the patient’s right to receive information about his/her care, treatment and/or services and to be involved in the decision-making process when appropriate… POLICY: Any discontinuation of care, treatment and/or services should be done in an appropriate manner and in such a way as to prevent harm to the patient… The patient should be an active participant, when possible, in planning his/her referral, transfer and/or discharge…” The 84th Texas Legislature, 2015, transferred programs and services from the Department of Aging and Disability Services to the Health and Human Services Commission effective September 1, 2017. Rule Chapters for Home and Community Support Services Agencies moved from TAC, Title 40, Part 1, Department of Aging and Disability Services, to TAC, Title 26, Part 1, Health and Human Services Commission as of May 1, 2019. 40 TAC Chapter 97 was transferred to 26 TAC Chapter 558. Record review of the online Texas Unified Licensure Information Portal (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 02/21/2025 included: The Adm was appointed the Adm (Texas Unified Licensure Information Portal RE-5598764) and the Alt Adm was appointed the Alt Adm (Texas Unified Licensure Information Portal RE-5598765) on 11/10/2017. Record review of the Adm’s personnel record emailed to the surveyor on 02/07/2025 included three training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider A, dated 05/20/2022, 07/28/2023, and 08/30/2024. The three training certificates included outdated information regarding TAC Chapter 97.260(a) and the Department of Aging and Disability Services. The three training certificates read in part, “… Meets 40 TAC 97.260(a)… [Continuing Education Provider A] is an approved provider of continuing education training by Texas Department of Aging and Disability Services.” TAC Chapter 97 transferred to Chapter 558 as of 05/01/2019. The Department of Aging and Disability Services transferred to The Health and Human Services Commission effective 05/01/2019. The record included two training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider B, dated 11/30/2023 and 11/30/2024. Record review of the Alt Adm’s personnel record emailed to the surveyor on 02/07/2025 included five training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider A, dated 05/04/2020, 08/31/2021, 05/20/2022, 07/28/2023 and 08/30/2024. The five training certificates included outdated information regarding TAC Chapter 97.260(a) and the Department of Aging and Disability Services. The five training certificates read in part, “… Meets 40 TAC 97.260(a)… [Continuing Education Provider A] is an approved provider of continuing education training by Texas Department of Aging and Disability Services.” TAC Chapter 97 transferred to Chapter 558 as of 05/01/2019. The Department of Aging and Disability Services transferred to The Health and Human Services Commission effective 05/01/2019. The record included two training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider B, dated 11/30/2023 and 11/30/2024. During an interview with Continuing Education Provider A on 02/11/2025 at 2:30 PM, the surveyor informed Continuing Education Provider A that the surveyor had observed training certificates for the Adm and Alt Adm and wanted to confirm the authenticity of the training certificates. The surveyor informed Continuing Education Provider A that the certificates depicted Continuing Education Provider A issued: The Adm a training certificate for 12 Administrative hours, dated 05/20/2022; a training certificate for 12 Administrative hours, dated 07/28/2023; and a training certificate for 12 Administrative hours, dated 08/30/2024 and; The Alt Adm a training certificate for 12 Administrative hours, dated 05/04/2020; a training certificate for 12 Administrative hours, dated 08/31/2021; a training certificate for 12 Administrative hours, dated 05/20/2022; a training certificate for 12 Administrative hours, dated 07/28/2023; and a training certificate for 12 Administrative hours, dated 08/30/2024. Continuing Education Provider A confirmed that the Adm and Alt Adm had not completed any training, nor were issued training certificates for any of the provided dates. Continuing Education Provider A stated the Adm and Alt Adm had never completed any training with Continuing Education Provider A at any time. During an interview with Continuing Education Provider B on 02/11/2025 at 2:11 PM, the surveyor informed Continuing Education Provider B that the surveyor had observed training certificates for the Adm and Alt Adm and wanted to confirm the authenticity of the training certificates. The surveyor informed Continuing Education Provider B that the certificates depicted Continuing Education Provider B issued the Adm and Alt Adm a training certificate for 12 Administrative hours, dated 11/30/2023 and a training certificate for 12 Administrative hours, dated 11/30/2024. Continuing Education Provider B requested the surveyor text message Continuing Education Provider B the certificate dates and the name of the Adm and Alt Adm. The surveyor texted the information on 02/11/2025 at 2:26 PM. On 02/11/2025 between 2:38 PM and 2:40 PM, the surveyor received three pictures from Continuing Education Provider B that included the Adm and Alt Adm completed 12 hours of continuing education on 11/30/2022. During an interview with Continuing Education Provider B on 02/11/2025 at 2:41 PM, Continuing Education Provider B confirmed that the Adm and Alt Adm completed 12 continuing education hours on 11/30/2022 but no additional continuing education hours were ever completed by the Adm and Alt Adm with Continuing Education Provider B. Continuing Education Provider B stated she was angry the agency used her certificates fraudulently. The surveyor did not receive a training certificate for the Adm and Alt Adm from Continuing Education Provider B dated 11/30/2022. During an interview with the Adm on 02/12/2025 at 2:07 PM, the surveyor asked where the Adm and Alt Adm’s continuing education training certificates given to the surveyor came from and if the continuing education was done in-person or on-line. The Adm stated one of the companies used was Continuing Education Provider A and those trainings were done on-line but he thought the other trainings were in-person. The surveyor reviewed the above findings and asked the Adm to explain how the training certificates were obtained. The Adm stated he would have to call Continuing Education Provider A and B because he previously received emails from Continuing Education Provider A and B stating the trainings had been completed. The Adm stated he would call or email the surveyor after he made the phone calls. The surveyor stated names of the persons he spoke with were needed so the surveyor could verify the information. The surveyor received an email from the Adm on 02/13/2025 at 9:32 AM that included 6 attachments that read in part, “… I tried to get in contact with the company which offered the certificates based in Houston and could not get them. I was told by a friend who used them before they had moved locations. Below are updated certificates obtained from [Continuing Education Provider A]. Let me know if anything else is needed…” The 6 attachments in the email included 3 training certificates for the continuing education in Administration of Agencies, issued by Continuing Education Provider A, for both the Adm and the Alt Adm dated 11/23/2023, 11/20/2024, and 02/12/2025. During an interview with Continuing Education Provider A on 02/14/2025 at 11:40 AM, the surveyor informed Continuing Education Provider A that the surveyor had observed training certificates for the Adm and Alt Adm and wanted to confirm the authenticity of the training certificates. The surveyor informed Continuing Education Provider A that the certificates depicted Continuing Education Provider A issued: Training certificates for 12 Administrative hours, dated 11/23/2023, 11/20/2024, and 02/12/2025. Continuing Education Provider A stated the training had not been completed with Continuing Education Provider A for any dates for the Adm and Alt Adm. Continuing Education Provider A stated online accounts had been set up by the agency, but no trainings had been done or completed. During a phone interview with the Adm on 02/14/2025 at 3:01 PM, the surveyor presented the above findings and asked if continuing education hours were completed on 11/23/2023, 11/20/2024 and 02/12/2025 with Continuing Education Provider A. The Adm stated he completed the continuing education hours listed on the Continuing Education Provider A certificates that were emailed to the surveyor. The Adm stated the certificates should be valid because the Adm and the Alt Adm completed the trainings. The surveyor requested a 3-way phone call between the Adm, the surveyor and Continuing Education Provider A to verify the information. The Adm stated he would let [Office Staff] handle the 3-way call. The surveyor ended the phone interview with the Adm on 02/14/2025 and heard Office Staff, located in the office next to the surveyors work area, on speakerphone with an unknown female regarding continuing education certificates. The surveyor entered Office Staff’s office and observed Office Staff on speakerphone. The surveyor asked who Office Staff was speaking with and Office Staff stated [Consultant]. The surveyor asked and received from Consultant her name, phone number and her employer. Consultant stated she worked for a consulting group who helped home health agencies and she was the consultant for [Agency]. Consultant stated she did not work for Continuing Education Provider A. Consultant further stated the 6 continuing education certificates for the Adm and Alt Adm dated 11/23/2023, 11/20/2024 and 02/12/2025 were valid and the continuing education hours were received from Continuing Education Provider A for the dates listed on the certificates. Consultant stated she sent the 6 certificates to the Adm. The surveyor presented the survey findings that Continuing Education Provider A reported continuing education hours had never been obtained by the Adm and Alt Adm from Continuing Education Provider A, that the 6 certificates were invalid and asked how Consultant obtained the 6 certificates. Consultant stated she did not know. The surveyor asked if the certificates were fabricated. Consultant put the 3-way call on hold and returned to the call approximately one minute later and stated Consultant falsified the 6 Continuing Education Provider A certificates for the Adm and Alt Adm for years 2023, 2025 and 2025 “to help them [Agency] out.” The surveyor asked to speak to Consultants manager and Consultant stated she was a manager at Consultant. Consultant further stated the Adm and Alt Adm missed continuing education hours since 2023 so she took it upon herself to create invalid certificates. During an interview with the Adm on 02/14/2025 at 3:26 PM, the surveyor presented the survey findings that the 6 continuing education certificates emailed to the surveyor on 02/13/2025 at 9:32 AM were fabricated and invalid and asked why the Adm stated he completed continuing education hours when he did not. The Adm stated he used Consultant for the continuing education hours and asked the surveyor why he would pay for something he would not use. The Adm stated he would have to deal with Consultant for saying the certificates were fabricated. The Adm stated he completed continuing education hours with Continuing Education Provider A. The surveyor offered a 3-way call between the Adm, the surveyor, and Continuing Education Provider A to verify the information. The Adm declined the 3-way call. During an interview with the Alt Adm on 02/12/2025 at 2:39 PM, the surveyor asked why continuing education training certificates given to the surveyor were invalid. The Alt Adm stated he did not know why, and he had completed continuing education training in 2022 but had not taken any continuing education training since 2022. Alt Adm stated he was unaware other continuing education training certificates existed, and he had not received additional training. The Alt Adm further stated he was unaware he needed to complete yearly continuing education training. During an interview with the Alt Adm on 02/14/2025 at 2:30 PM, the Alt Adm stated he did not take continuing education hours for the Alt Adm position, and he did not know anything about the fraudulent certificates given to the surveyor by the Adm. During a telephone interview with the Adm on 02/14/2025 at 3:16 pm, the Adm stated agency polices were not followed because they were things the agency overlooked. Agency policy titled, “Policy 1.45: CONTINUING EDUCATION FOR ADMINISTRATORS” undated, read in part, “… PURPOSE: To provide a process for recognizing and applying state regulatory requirements for a (sic) ongoing continuing education, and training for the administrator and management staff within the framework of administrative policy and procedures that: Develop and enhance employees’ skills; Broaden and increase employee’s knowledge base; Maintain and improve staff competency. POLICY: State regulatory requirements for continuing education are identified and applied within the context of administrative policy…” Agency policy titled, “Policy 1.21: AGENCY ADMINISTRATION” undated, read in part, “… POLICY: The Board of Directors shall appoint a full-time Administrator who shall have a full authority for management of Agency affairs… PROCEDURE: The Administrator shall have the overall authority and responsibility for agency operations… 2. Managing the Agency…” Agency policy titled, “Policy 1.4: MAINTENANCE OF POLICIES AND PROCEDURES” undated, read in part, “… PURPOSE: To ensure that the Agency policies and procedures are enforced. POLICY: All policies and procedures adopted… shall be enforced… PROCEDURE: 1. The Agency administrator is responsible for ensuring that all policies and procedures are enforced. 2. Any violation of the polices (sic) and procedures shall result in disciplinary action, suspension, termination, or reporting to the appropriate licensing authority as appropriate…””