Texas Premier Home Healthcare, Inc.

“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 completed written Notice of Medicare Non-Coverage notice at least two days in advance of terminating on-going care in two of two patient discharged records (Patients 4 and 5) reviewed with a discharge reason of goals met. The failure of the agency to protect the rights of the patient by informing in advance of their right to appeal the discontinuation of home health services prevented the identified patients from exercising their right to appeal the discharge decision if they chose to appeal. Findings included: During an interview with the Administrator on 12/16/2025 at 11:30 AM, the Administrator stated the Director of Nurses/Supervising Nurse was responsible for ensuring the written Notice of Medicare Non-Coverage forms were given as required. Patient 4: Record review of the electronic medical record included a plan of care dated 09/16/2024 to 11/14/2024 signed by the Director of Nurses/Supervising Nurse on 09/15/2024 with a start of care date of 02/15/2019. The physician ordered the nurse to visit the patient once a week for nine weeks. The record included a discharge visit conducted on 11/14/2024 by the Director of Nurses/Supervising Nurse with a discharge reason of goals met. Also included was a written Notice of Medicare Non-Coverage that was signed and dated by Patient 4 on 11/14/2024, the same day of discharge. The written Notice of Medicare Non-Coverage notice was not provided at least two days in advance of terminating on-going care on 11/14/2024. In an interview with the Administrator on 12/18/2025 at 1:28 PM, the surveyor reviewed the findings and asked why the written Notice of Medicare Non-Coverage notice was not provided at least two days in advance of terminating on-going care. The Administrator stated he had no idea. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 1:55 PM, the surveyor reviewed the findings and asked why the written Notice of Medicare Non-Coverage notice was not provided at least two days in advance of terminating on-going care. The Director of Nurses/Supervising Nurse stated the notice should have been given at least 2 days in advance of discharge and it was an oversight that it was not. Patient 5: Record review of the electronic medical record included a plan of care dated 04/11/2024 to 06/09/2024 signed by the Director of Nurses/Supervising Nurse on 04/11/2024 with a start of care date of 04/11/2024. The physician ordered the nurse to visit the patient once a month for two months. The record included a discharge visit conducted on 06/05/2024 by the Director of Nurses/Supervising Nurse with a discharge reason of goals met. The record did not include a written Notice of Medicare Non-Coverage. The record included a face-to-face physician visit note signed by Doctor of Osteopathic Medicine on 04/25/2025 that included orders for physical therapy. Thirteen physical therapy visits were conducted between 04/16/2024-06/05/2024. An email was sent to the Administrator on 12/18/2025 at 1:03 PM asking if the agency had a written Notice of Medicare Non-Coverage for Patient 5. An email was received from the Administrator on 12/18/2025 at 2:14 PM that read, “I can’t find it now.” In an interview with the Administrator on 12/18/2025 at 3:00 PM, the surveyor reviewed the findings and asked why the written Notice of Medicare Non-Coverage notice was not provided at least two days in advance of terminating on-going care. The Administrator stated if the agency found the notice, it would be provided to the surveyor but if the surveyor did not receive it from the agency, it was because it was not found. The Administrator stated it was the same answer given for Patient 4 [he had no idea]. The surveyor did not receive the discharge notice. In an interview with the Administrator on 12/18/2025 at 3:04 PM, the surveyor reviewed the findings and asked why agency policy was not followed. The Administrator stated it was an oversight. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 1:55 PM, the surveyor reviewed the findings and asked why the written Notice of Medicare Non-Coverage notice was not provided at least two days in advance of terminating on-going care. The Director of Nurses/Supervising Nurse stated the notice should have been given at least 2 days in advance of discharge and it was an oversight that it was not provided. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 2:00 PM, the surveyor asked why agency policy was not followed. The Director of Nurses/Supervising Nurse stated she had an administrative role in performing quality assurance activities (system designed to monitor and improve the quality of healthcare services provided to clients in their homes) at the same time she completed clinical visits which blurred her eyes with different lenses and affected the outcome. Agency policy titled, “PATIENT DISCHARGE PE.6” with a revision date of 08/01/2014 read in part, “… Agency will deliver the Notice of Medicare Non-Coverage… at least 2 calendar days before Medicare covered services end…””

“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 interview, the agency failed to ensure the plan of cares included the rehabilitation potential and patient-specific interventions in five of seven records reviewed (Patient 1, 2, 3, 4 and 5) in that: a. In one of five records reviewed (Patient 1), the plan of care did not include the rehabilitation potential. b. In one of seven records reviewed (Patient 2), the plan of care did not include bleeding safety measures for a blood thinning medication (Eliquis). c. In one of seven records reviewed (Patient 3), the plan of care did not include blood sugar and pain parameters to report to the physician. d. In one of seven records reviewed (Patient 4), the plan of care did not include pain parameters to report to the physician. e. In one of seven records reviewed (Patient 5), the plan of care did not include blood sugar parameters to report to the physician and who was to monitor the blood sugar levels. 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 and at risk of declining health status and complications. Findings included: In an interview with the Administrator on 12/16/2025 at 11:30 AM, the Administrator stated the Director of Nurses/Supervising Nurse was responsible for ensuring the plan of cares included all the required elements. Patient 1: Record review of the electronic medical record included a plan of care dated 03/05/2024 to 05/03/2024 signed by the Director of Nurses/Supervising Nurse on 03/01/2024 with a start of care date of 11/06/2023. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of joint pain and stiffness; high blood pressure; the loss of thinking, remembering, and reasoning; and heart disease. The plan of care did not include the rehabilitation potential. In an interview with the Administrator on 12/18/2025 at 3:03 PM, the surveyor reviewed the findings and asked why the plan of care did not include the rehabilitation potential. The Administrator stated it was an oversight. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 2:00 PM, the surveyor reviewed the findings and asked why the plan of care did not include the rehabilitation potential. The Director of Nurses/Supervising Nurse stated it was an oversight, and she would not have remembered to include it if someone at the agency had not assigned it to her to populate in the electronic record. Patient 2: Record review of the electronic medical record included a plan of care dated 03/31/2025 to 05/29/2025 signed by the Director of Nurses/Supervising Nurse on 03/27/2025 with a start of care date of 04/05/2024. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of joint pain and stiffness; lung disease; heart disease; and abnormal heartbeats. The plan of care did not include bleeding safety measures for a blood thinning medication. In an interview with the Administrator on 12/18/2025 at 2:34 PM, the surveyor reviewed the findings and asked why the plan of care did not include bleeding safety measures. The Administrator stated he did not know. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 1:45 PM, the surveyor reviewed the findings and asked why the plan of care did not include bleeding safety measures. The Director of Nurses/Supervising Nurse stated it was an oversight. Patient 3: Record review of the electronic medical record included a plan of care dated 09/05/2024 to 11/03/2024 signed by the Director of Nurses/Supervising Nurse on 09/03/2024 with a start of care date of 05/08/2024. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of high blood sugar levels; nerve pain; and the loss of thinking, remembering, and reasoning. The plan of care included three medications to be injected into the body with a needle to lower blood sugar levels (Levemir, Novolog, and Tresiba) and three medications to be swallowed to lower blood sugar levels (Nateglinide, Pioglitazone and Tradjenta). The plan of care read in part, “… SN to provide skilled assessment, teaching/training and reinforcement of teaching to properly assess, manage and mitigate (lessen) pain. SN to instruct on measures to mitigate pain including Tylenol (pain medication) medication administration, recording and reporting pain; non-pharmacological (without medication) treatments including positioning, massage, visualization, distraction… SN to assess diabetic (high blood sugar levels) status, identify any signs and symptoms of impaired diabetic function, report significant changes to physician… Patient with moderate pain…” The plan of care did not include blood sugar and pain parameters to report to the physician. In an interview with the Administrator on 12/18/2025 at 2:42 PM, the surveyor reviewed the findings and asked why the plan of care did not include blood sugar and pain parameters to report to the physician. The Administrator stated he did not know. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 1:45 PM, the surveyor reviewed the findings and asked why the plan of care did not include blood sugar and pain parameters to report to the physician. The Director of Nurses/Supervising Nurse stated when she did patient assessments and developed the plan of care, she also did quality assurance (system designed to monitor and improve the quality of healthcare services provided to patients in their homes) at the same time which resulted in the information being overlooked. The Director of Nurses/Supervising Nurse further stated she did not have the best set of quality assurance eyes since she was not a quality assurance nurse. Patient 4: Record review of the electronic medical record included a plan of care dated 09/16/2024 to 11/14/2024 signed by the Director of Nurses/Supervising Nurse on 09/15/2024 with a start of care date of 02/15/2019. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of nerve pain and joint pain and stiffness. The plan of care included one pain medication to be swallowed (Meloxicam) and one pain medication to apply on the skin (Voltaren gel). The plan of care read in part, “… Goals… Pt/Cg will verbalize understanding to observe for nonverbal indicators of pain: moaning, guarding, crying, facial grimace…” The plan of care did not include pain parameters to report to the physician. In an interview with the Administrator on 12/18/2025 at 2:49 PM, the surveyor reviewed the findings and asked why the plan of care did not include pain parameters to report to the physician. The Administrator stated he did not know. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 1:55 PM, the surveyor reviewed the findings and asked why the plan of care did not include pain parameters to report to the physician. The Director of Nurses/Supervising Nurse stated it was the same answer given for Patient 3 [when she did patient assessments and developed the plan of care, she also did quality assurance at the same time which resulted in the information being overlooked]. The Director of Nurses/Supervising Nurse further stated she did not have the best set of quality assurance eyes since she was not a quality assurance nurse. Patient 5: Record review of the electronic medical record included a plan of care dated 04/11/2024 to 06/09/2024 signed by the Director of Nurses/Supervising Nurse on 04/11/2024 with a start of care date of 04/11/2024. The physician ordered the nurse to visit the patient once a month for two months. The plan of care included a diagnosis of high blood sugar levels and one medication to be swallowed to lower blood sugar levels (Glimepiride). The plan of care did not include blood sugar parameters to report to the physician and who was to monitor the blood sugar levels. In an interview with the Administrator on 12/18/2025 at 3:00 PM, the surveyor reviewed the findings and asked why the plan of care did not include blood sugar parameters to report to the physician and who was to monitor the blood sugar levels. The Administrator stated he did not know. In an interview with the Administrator on 12/18/2025 at 3:04 PM, the surveyor reviewed the findings and asked why agency policy was not followed. The Administrator stated it was an oversight. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 1:55 PM, the surveyor reviewed the findings and asked why the plan of care did not include blood sugar parameters to report to the physician and who was to monitor the blood sugar levels. The Director of Nurses/Supervising Nurse stated it was the same answer given for Patient 3 [when she did patient assessments and developed the plan of care, she also did quality assurance at the same time which resulted in the information being overlooked]. The Director of Nurses/Supervising Nurse further stated she did not have the best set of quality assurance eyes since she was not a quality assurance nurse. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 2:00 PM, the surveyor asked how patients could be affected when all required elements were not included in the plan of cares. The Director of Nurses/Supervising Nurse stated it could affect the patients’ health outcomes by not planning care that was specific to each patient. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 2:00 PM, the surveyor asked why agency policy was not followed. The Director of Nurses/Supervising Nurse stated she had an administrative role in performing quality assurance activities at the same time she completed clinical visits which blurred her eyes with different lenses and affected the outcome. Agency policy titled, “Plan of Care TX.6” with a revision date of 03/16/2004 read in part, “… Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems… Procedure I. The appropriate licensed professional staff member, with physician participation, is responsible for developing the plan of care… 3. The 485, which includes the following plan of care elements, will serve as the initial plan of care… interventions and care… ””

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure nursing services were provided under the supervision of a Registered Nurse and according to agency policy in three of five records (Patient 2, 4, and 6) reviewed whose supervisory visits were due and where the agency LVN’s (LVN A and LVN B) conducted skilled nursing visits. This failure placed patients at risk of harmful or inadequate care in the event issues with service delivery were not identified and corrected. Findings included: Patient 2: Record review of the electronic medical record included a plan of care dated 03/31/2025 to 05/29/2025 signed by the Director of Nurses/Supervising Nurse on 03/27/2025 with a start of care date of 04/05/2024. The physician ordered the nurse to visit the patient once a week for nine weeks. Eight skilled nursing visits were conducted by LVN A on the following dates: 04/03/2025; 04/10/2025; 04/17/2025; 04/24/2025; 05/01/2025; 05/08/2025; 05/15/2025; 05/22/2025. The Director of Nurses/Supervising Nurse conducted a recertification visit on 05/27/2025. The visit did not include evidence that an LVN Supervisory Visit was conducted. Review of the entire record did not include evidence that an LVN Supervisory Visit was conducted. Patient 4: Record review of the electronic medical record included a plan of care dated 09/16/2024 to 11/14/2024 signed by the Director of Nurses/Supervising Nurse on 09/15/2024 with a start of care date of 02/15/2019. The physician ordered the nurse to visit the patient once a week for nine weeks. Eight skilled nursing visits were conducted by LVN B on the following dates: 09/16/2024; 09/23/2024; 09/30/2024; 10/07/2024; 10/14/2024; 10/21/2024; 10/28/2024; 11/04/2024. The Director of Nurses/Supervising Nurse conducted a discharge visit on 11/14/2024. The visit did not include evidence that an LVN Supervisory Visit was conducted. Review of the entire record did not include evidence that an LVN Supervisory Visit was conducted. Patient 6: Record review of the electronic medical record included a plan of care dated 03/28/2025 to 05/26/2025 signed by the Director of Nurses/Supervising Nurse on 03/25/2025 with a start of care date of 07/31/2024. The physician ordered the nurse to visit the patient once a week for nine weeks. Eight skilled nursing visits were conducted by LVN A on the following dates: 03/28/2025; 04/03/2025; 04/10/2025; 04/17/2025; 04/24/2025; 05/01/2025; 05/09/2025; 05/16/2025. The Director of Nurses/Supervising Nurse conducted a recertification visit on 05/26/2025. The visit did not include evidence that an LVN Supervisory Visit was conducted. Review of the entire record did not include evidence that an LVN Supervisory Visit was conducted. In an interview with the Administrator on 12/18/2025 at 2:34 PM, the surveyor reviewed the findings and asked why LVN Supervisory Visits were not conducted for Patient 2, 4, and 6. The Administrator stated supervisory visits would be included in the electronic record if they had been done. The Administrator further stated the Director of Nurses/Supervising Nurse could have forgotten about them. In an interview with the Administrator on 12/18/2025 at 3:04 PM, the surveyor reviewed the findings and asked why agency policy was not followed. The Administrator stated it was an oversight. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 1:42 PM, the surveyor reviewed the findings and asked why LVN Supervisory Visits were not conducted for Patient 2, 4, and 6. The Director of Nurses/Supervising Nurse stated if the supervisory visits were not scheduled to her in the electronic record to complete, she would not have completed them. The Director of Nurses/Supervising Nurse stated the supervisory visits were overlooked. In an interview with the Director of Nurses/Supervising Nurse on 12/22/2025 at 2:00 PM, the surveyor asked why agency policy was not followed. The Director of Nurses/Supervising Nurse stated she had an administrative role in performing quality assurance activities at the same time she completed clinical visits which blurred her eyes with different lenses and affected the outcome. Agency policy titled, “Employee Supervision HR.11” with a revision date of 07/01/2014 read in part, “… PURPOSE To establish employee supervision practices In accordance with applicable federal and state laws and regulations… POLICY Agency will provide timely supervision of the following employees by qualified Individuals… Licensed Vocational Nurse (LVN) By a Registered Nurse at least every 60 days…””