Best Choice Home Care Inc.

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects for 3 (2023, 2024 and 2025) of 3 years of QAPI records reviewed. This failure potentially placed patients at risk of poor health outcomes when the agency failed to identify and address areas of the home health’s program for which performance could be improved. FINDINGS INCLUDE: Review of the undated documentation regarding the agency’s QAPI Program included no documentation to indicate the home health agency had developed, implemented and described the reasons for conducting the projects, or evaluated the measurable progress achieved for the years of 2023, 2024 and 2025. During an interview on 04/23/2026 at 2:30 PM, with the Administrator and Alternate Administrator, the Surveyor reviewed the findings and asked if the agency had completed and documented any PIPs. The Administrator stated, “Since the agency hasn’t had any Medicare patients, I wasn’t sure those reports were necessary. I know everything comes back to the Administrator and I’m ultimately responsible.””

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on record review and interview, the agency failed to employ or contract a Clinical Manager. In 1 (RN A) of 1 RN personnel file reviewed for Clinical Manager compliance, the RN was no longer employed by the agency and was not willing to provide oversight of patient care services and personnel. The agency failed to employ or contract a licensed professional Clinical Manager. Failure of the agency to ensure staffing included a Clinical Manager who was able and willing to provide oversight of patient care and personnel services, potentially caused the agency to be unable to maintain its compliance structure to provide skilled services to patients. FINDINGS INCLUDE: On 04/16/2026, during Pre-survey review in 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), the Surveyor noted the person listed in the position of Clinical Manager. In an interview during the entrance conference on 04/17/2026 at 10:00 AM, with the Alternate Administrator, the Surveyor asked if the names of the RN’s listed in TULIP as the Clinical Manager for the agency was current information. The Alternate Administrator stated, “Yes.” The Surveyor requested the Clinical Manager personnel record for review. On 04/17/2026 at 11:20 AM, the surveyor received an employee list. A Clinical Manager and was not included on the list. Review of the personnel file for RN A revealed an application for employment dated 04/17/2019. The application included, “… Position Applying For: Director of Nursing …” The form was signed and dated by RN A listed in TULIP as the Clinical Manager 04/17/2019. The file contained a job description for the Title, “Supervising Nurse/Clinical Manager.” The form was dated 04/17/19 (2019) and signed by RN A. In a phone interview on 04/20/2026 at 3:00 PM with RN A, the Surveyor asked if RN A was currently the Clinical Manager for the agency. RN A stated she was not the agency’s Clinical Manager. She stated she attempted to contact the agency Administrator and render a resignation, but phone calls and emails were not returned. RN A stated she contacted the HCSSA licensing department and reported she was no longer the Clinical Manager for the agency effective 09/29/2025. On 04/20/2026 at 3:10 PM, the Surveyor received an email from RN A that included a forwarded message from RN A to HCSSA Licensing department that read in part, “… To whom it may concern, Please be aware that I (RN A), am no longer the Supervising Nurse effective 09/29/2025 to the following agency: Agency, Identifier E … .” In a phone interview on 04/20/2026 at 3:15 PM with the HHSC Licensing associate, Identifier C, the Surveyor asked if the agency had submitted a change in the agency’s Clinical Manager position. Identifier C stated the last notification from the agency was November 2025 for a change in the Alternate Administrator position only. The agency had not notified HHSC Licensing department of a change in the agency’s Clinical Manager. In an interview with the Administrator on 04/23/2026 at 1:20 PM, the Surveyor reviewed the findings and asked if the Administrator was aware the agency did not have a Clinical Manager that was willing to act in the position of a Clinical Manager. The Administrator stated, “Yes.” The Surveyor asked how long she had been aware the agency did not have a Clinical Manager, employee or contracted employee assigned in the position of Clinical Manager. The Administrator stated, “about 4-5 months.” The Surveyor asked why the agency did not have a Clinical Manager. The Administrator stated there have been no skilled services or patient referrals for skilled services. The Administrator stated the agency had recently been approved for a Medicare program but did not believe it included skilled services. The Administrator stated she thought the previous Clinical Manager (RN A) would have stayed on until the Administrator decided to grow the home health (skilled) side. Agency policy, revised date 05/01/2024, quoted in part, “Responsibilities of the Administrator, Purpose: To define the responsibilities of the Administrator to ensure Agency compliance with applicable state and local laws and regulations as appropriate. Policy: I. The Agency Administrator will assume overall responsibility and authority for administrative and leadership functions and responsibility for ongoing communication with the entire Agency staff. … Procedure: I. The Agency defines the responsibilities of the Administrator to include, but not be limited to: … J. Employing and contracting with qualified personnel … II. The Administrator will identify resources needed to implement his or her responsibilities… .” Agency policy, revised date 01/13/2018, quoted in part, “RESPONSIBILITIES OF THE SUPERVISING NURSE, … DEFINITION: The Supervising Nurse is the Registered Nurse responsible for supervising skilled services provided by the agency and who meets the qualifications defined by regulation. This person may also be known as the Director of Nurses, Director of Home Health, Clinical Manager or a similar title. … POLICY: The Supervising Nurse and Alternate Supervising Nurse must each be a registered nurse (RN) licensed in Texas … PROCEDURE: I. … F. Being available to Agency personnel at all times in person or by telephone (Supervising Nurse or Alternate), … N. Ensuring the care offered by the Agency, … is consistently available to all patients/clients, … .””