Amazon Health Services

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on observation, records review and interview, the agency failed to ensure the ongoing interdisciplinary assessment of the patient in that the surveyor was not granted entry into the agency on 6-16-26 or 6-17-26 to conduct the recertification survey. The surveyor left the agency unable to conduct recertification survey and unable to verify if agency had patients and if skilled professionals were assuming the responsibility for ongoing interdisciplinary assessment of the patients (Refer to G706). Refer to G0706 - Interdisciplinary assessment of the patient”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on observation, record review, and interview,the agency failed to ensure the HHA managed and administered its resources to attain and maintain the highest practicable functional capacity in that: The Administrator failed to be responsible for all day-to-day operations of the agency when Administrator failed to be available to provide entry for HHSC surveyor to complete survey on 6/16/26 and 6/17/26 (Refer to G948). The Administrator or pre-designated person failed to be available during all operating hours to provide entry for HHSC surveyor to complete survey on 6/16/26 and 6/17/26 (Refer to G956). Refer to G0948-Responsible for all day-to-day operations and G0956-Available during all operating hours”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, records review and interview, the agency failed to ensure the ongoing interdisciplinary assessment of the patient in that the surveyor was not granted entry into the agency on 6-16-26 or 6-17-26 to conduct the recertification survey and unable to verify if agency had patients and if skilled professionals were assuming the responsibility for ongoing interdisciplinary assessment of the patients This failure could place patients at risk of receiving substandard care and services. Record review of TULIP (Texas Unified license Information Portal – is a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 6-15-26 revealed the agency address contact information as: Address A. and phone number as Telephone B. The agency operational hours were listed as 9am – 5pm. Monday through Friday. Further review of hospice’s TULIP account revealed the agency’s patients census was 24 as of 1-19-24. Review of the agency’s IQIES (stands for the Internet Quality Improvement and Evaluation System. It is a secure, cloud-based web portal managed by the Centers for Medicare & Medicaid Services (CMS).The system is used by healthcare providers, state survey agencies, and CMS staff to submit, analyze, and report patient assessment and facility quality data) revealed the agency address was the same as shown in the agency’s TULIP account. On 6-16-26 at 8: 30 AM the Surveyor arrived at Address A. Observation at this time revealed there was a person sitting at a desk at the entry of the suite. At this time the Surveyor asked for the agency. The person sitting at the desk stated that the agency had not been at address A in over a year. Record review of TULIP on 6-16-26 at 8:45 am revealed there had been no address update noted in the system. At this time the Surveyor proceeded to the building lobby. On 6-16-26 at 9:12 am the Surveyor called the agency telephone number listed in TULIP. There was no answer to phone. At this time the Surveyor left a message for administrator or alternate administrator to call surveyor regarding survey. On 6-16-26 at 9:56 am the Surveyor placed a call to the agency’s telephone number . During the call the Surveyor pressed the zero prompt for the agency administrator. At this time the phone seemed to be picked up, the Surveyor heard what seemed to be noise then the phone hang up, no one answered or responded to surveyor. On 6-16-26 at 10:46 am the Surveyor placed a call to agency. A t this time a person answering the phone stated they were the Owner of the agency. The Owner stated he did not get the message the Surveyor left earlier (9:12 am) . The owner was made aware that the surveyor was attempting to do the agency recertification survey. The Owner stated that he was told by Licensing personnel in the State office that the agency’s survey was not going to be until August or September. At this time the Surveyor asked if the agency relocated. The Owner stated that the agency recently moved and that he called State office approximately 3 weeks ago (when he received the information about filling out form 855a). The Owner further stated he was told by State office personnel that he would need to fill out form 855a ( an official form used by institutional healthcare providers to enroll, update or terminate Medicare billing privileges) to change the agency address. At this time the Owner stated that the form was not done. The Owner stated the agency new address was located at Address B. The owner also stated that the administrator has changed to administrator B and the alternate Supervising Nurse also changed. The Owner further stated that the agency had no current patients and they had not billed in months. At 11:00 am the Surveyor left agency address A noted in TULIP. On 6-17-26 at 11:15 am the Surveyor arrived at location (Address B). At this time the Surveyor spoke to the building personnel in the communal lobby desk area. The building personnel stated that she would go back to see if agency personnel was in their office. Building personnel returned a minute later and stated the agency staff was not in the office but that she would call them. Observation on 6-17-26 at 11:18 am, Surveyor observed Address B building personnel calling the agency Owner. At this time the building personnel stated the agency Owner stated he would call her right back. Approximately one minute later the building personnel received a return call and stated that the agency Owner wanted to talk to the Surveyor. During a telephone interview on 6-17-26 at 11:21 am the agency owner stated that he was out of town until next Wednesday and would not be able to come to the agency. The Surveyor then asked the Owner who had the agency put in place to allow the Surveyor entry. The Owner stated himself, Administrator/Supervising Nurse, Alternate Administrator or the Alternate Supervising Nurse. The Surveyor then requested that the Owner call the Administrator or Alternate Administrator to be available for the survey and let the Surveyor into the agency. The agency Owner stated the Administrator/Supervising Nurse would not be available to allow surveyor entry within 2 hours of arrival and the Alternate Administrator was currently in Dallas, Texas. At this time the Surveyor asked about the Alternate Supervising Nurse. The Owner stated he would try to call the Alternate Supervising Nurse. During a return call from the agency Owner on 6-17-26 at 11:42 am the Owner stated that he had tried to call the Alternate Supervising Nurse. However, The Alternate Supervising Nurse was not answering the calls. The Owner was made aware that the Surveyor would wait the 2 hours from arrival (11:15 am) and the Owner stated that if the Alternate Supervising Nurse returned his call he would call and let the Surveyor know. During an observation on 6-17-26 at 11:53 am the communal building personnel lead the Surveyor to the agency’s unmarked agency office door. There was no activity at the office. The Surveyor went to the entry lobby of building 12:15pm , no return call from agency staff or agency Owner. The Surveyor was noted in entry Lobby of building at 1:15 pm , no return call from agency staff or agency Owner. At 2:11 pm on 6-17-26 the Surveyor returned to the communal lobby area and spoke to the building personnel at desk. The building personnel stated that no one from the agency had arrived at the agency office but that she would go back and check for the Surveyor. The communal desk personnel returned and stated that no one from the agency was at the agency office. At this time the surveyor left the agency building. The surveyor was unable the conduct recertification survey and unable to verify if agency had patients and if skilled professionals were assuming the responsibility for ongoing interdisciplinary assessment of the patients The Surveyor sent the agency via email the letter of inability to conduct a federal survey on 6-17-26 at 5:01 pm.”

“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 observation, record review, and interview, the agency Administrator failed to be responsible for all day-to-day operations of the agency In that, the Administrator and Alternate Administrator were not available to the Surveyor to allow entry into the agency and to start the survey. This failure could place patients at risk of receiving substandard care and services Record review of TULIP (Texas Unified license Information Portal – is a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 6-15-26 revealed the agency address contact information as: Address A. and phone number as Telephone B. The agency operational hours were listed as 9am – 5pm. Monday through Friday. Further review of hospice’s TULIP account revealed the agency’s patients census was 24 as of 1-19-24. Review of the agency’s IQIES (stands for the Internet Quality Improvement and Evaluation System. It is a secure, cloud-based web portal managed by the Centers for Medicare & Medicaid Services (CMS).The system is used by healthcare providers, state survey agencies, and CMS staff to submit, analyze, and report patient assessment and facility quality data) revealed the agency address was the same as shown in the agency’s TULIP account. On 6-16-26 at 8: 30 AM the Surveyor arrived at Address A. Observation at this time revealed there was a person sitting at a desk at the entry of the suite. At this time the Surveyor asked for the agency. The person sitting at the desk stated that the agency had not been at address A in over a year. Record review of TULIP on 6-16-26 at 8:45 am revealed there had been no address update noted in the system. At this time the Surveyor proceeded to the building lobby. On 6-16-26 at 9:12 am the Surveyor called the agency telephone number listed in TULIP. There was no answer to phone. At this time the Surveyor left a message for administrator or alternate administrator to call surveyor regarding survey. On 6-16-26 at 9:56 am the Surveyor placed a call to the agency’s telephone number . During the call the Surveyor pressed the zero prompt for the agency administrator. At this time the phone seemed to be picked up, the Surveyor heard what seemed to be noise then the phone hang up, no one answered or responded to surveyor. On 6-16-26 at 10:46 am the Surveyor placed a call to agency. A t this time a person answering the phone stated they were the Owner of the agency. The Owner stated he did not get the message the Surveyor left earlier (9:12 am) . The owner was made aware that the surveyor was attempting to do the agency recertification survey. The Owner stated that he was told by Licensing personnel in the State office that the agency’s survey was not going to be until August or September. At this time the Surveyor asked if the agency relocated. The Owner stated that the agency recently moved and that he called State office approximately 3 weeks ago (when he received the information about filling out form 855a). The Owner further stated he was told by State office personnel that he would need to fill out form 855a ( an official form used by institutional healthcare providers to enroll, update or terminate Medicare billing privileges) to change the agency address. At this time the Owner stated that the form was not done. The Owner stated the agency new address was located at Address B. The owner also stated that the administrator has changed to administrator B and the alternate Supervising Nurse also changed. The Owner further stated that the agency had no current patients and they had not billed in months. At 11:00 am the Surveyor left agency address A noted in TULIP. On 6-17-26 at 11:15 am the Surveyor arrived at location (Address B). At this time the Surveyor spoke to the building personnel in the communal lobby desk area. The building personnel stated that she would go back to see if agency personnel was in their office. Building personnel returned a minute later and stated the agency staff was not in the office but that she would call them. Observation on 6-17-26 at 11:18 am, Surveyor observed Address B building personnel calling the agency Owner. At this time the building personnel stated the agency Owner stated he would call her right back. Approximately one minute later the building personnel received a return call and stated that the agency Owner wanted to talk to the Surveyor. During a telephone interview on 6-17-26 at 11:21 am the agency owner stated that he was out of town until next Wednesday and would not be able to come to the agency. The Surveyor then asked the Owner who had the agency put in place to allow the Surveyor entry. The Owner stated himself, Administrator/Supervising Nurse, Alternate Administrator or the Alternate Supervising Nurse. The Surveyor then requested that the Owner call the Administrator or Alternate Administrator to be available for the survey and let the Surveyor into the agency. The agency Owner stated the Administrator/Supervising Nurse would not be available to allow surveyor entry within 2 hours of arrival and the Alternate Administrator was currently in Dallas, Texas. At this time the Surveyor asked about the Alternate Supervising Nurse. The Owner stated he would try to call the Alternate Supervising Nurse. During a return call from the agency Owner on 6-17-26 at 11:42 am the Owner stated that he had tried to call the Alternate Supervising Nurse. However, The Alternate Supervising Nurse was not answering the calls. The Owner was made aware that the Surveyor would wait the 2 hours from arrival (11:15 am) and the Owner stated that if the Alternate Supervising Nurse returned his call he would call and let the Surveyor know. During an observation on 6-17-26 at 11:53 am the communal building personnel lead the Surveyor to the agency’s unmarked agency office door. There was no activity at the office. The Surveyor went to the entry lobby of building 12:15pm , no return call from agency staff or agency Owner. The Surveyor was noted in entry Lobby of building at 1:15 pm , no return call from agency staff or agency Owner. At 2:11 pm on 6-17-26 the Surveyor returned to the communal lobby area and spoke to the building personnel at desk. The building personnel stated that no one from the agency had arrived at the agency office but that she would go back and check for the Surveyor. The communal desk personnel returned and stated that no one from the agency was at the agency office. At this time the surveyor left the agency building. The surveyor was unable to conduct the recertification survey and unable to verify if agency had patients due to the Administrator and Alternate Administrator were not available to the Surveyor to allow entry into the agency to start the recertification survey to verify compliance with the regulations The Surveyor sent the agency via email the letter of inability to conduct a federal survey on 6-17-26 at 5:01 pm.”

“Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This Element is not met as evidenced by: Based on observation, record review, and interview the agency Administrator or predesignated person failed to be available during all operating hours In that, an attempted recertification survey visit was made on 6-16-26 and 6-17-26 at the agency’s physical location listed in IQIES and new Address B. The surveyor was unable to conduct a recertification survey This failure could place patients at risk of receiving substandard care and services. Record review of TULIP (Texas Unified license Information Portal – is a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 6-15-26 revealed the agency address contact information as: Address A. and phone number as Telephone B. The agency operational hours were listed as 9am – 5pm. Monday through Friday. Further review of hospice’s TULIP account revealed the agency’s patients census was 24 as of 1-19-24. Review of the agency’s IQIES (stands for the Internet Quality Improvement and Evaluation System. It is a secure, cloud-based web portal managed by the Centers for Medicare & Medicaid Services (CMS).The system is used by healthcare providers, state survey agencies, and CMS staff to submit, analyze, and report patient assessment and facility quality data) revealed the agency address was the same as shown in the agency’s TULIP account. On 6-16-26 at 8: 30 AM the Surveyor arrived at Address A. Observation at this time revealed there was a person sitting at a desk at the entry of the suite. At this time the Surveyor asked for the agency. The person sitting at the desk stated that the agency had not been at address A in over a year. Record review of TULIP on 6-16-26 at 8:45 am revealed there had been no address update noted in the system. At this time the Surveyor proceeded to the building lobby. On 6-16-26 at 9:12 am the Surveyor called the agency telephone number listed in TULIP. There was no answer to phone. At this time the Surveyor left a message for administrator or alternate administrator to call surveyor regarding survey. On 6-16-26 at 9:56 am the Surveyor placed a call to the agency’s telephone number . During the call the Surveyor pressed the zero prompt for the agency administrator. At this time the phone seemed to be picked up, the Surveyor heard what seemed to be noise then the phone hang up, no one answered or responded to surveyor. On 6-16-26 at 10:46 am the Surveyor placed a call to agency. A t this time a person answering the phone stated they were the Owner of the agency. The Owner stated he did not get the message the Surveyor left earlier (9:12 am) . The owner was made aware that the surveyor was attempting to do the agency recertification survey. The Owner stated that he was told by Licensing personnel in the State office that the agency’s survey was not going to be until August or September. At this time the Surveyor asked if the agency relocated. The Owner stated that the agency recently moved and that he called State office approximately 3 weeks ago (when he received the information about filling out form 855a). The Owner further stated he was told by State office personnel that he would need to fill out form 855a ( an official form used by institutional healthcare providers to enroll, update or terminate Medicare billing privileges) to change the agency address. At this time the Owner stated that the form was not done. The Owner stated the agency new address was located at Address B. The owner also stated that the administrator has changed to administrator B and the alternate Supervising Nurse also changed. The Owner further stated that the agency had no current patients and they had not billed in months. At 11:00 am the Surveyor left agency address A noted in TULIP. On 6-17-26 at 11:15 am the Surveyor arrived at location (Address B). At this time the Surveyor spoke to the building personnel in the communal lobby desk area. The building personnel stated that she would go back to see if agency personnel was in their office. Building personnel returned a minute later and stated the agency staff was not in the office but that she would call them. Observation on 6-17-26 at 11:18 am, Surveyor observed Address B building personnel calling the agency Owner. At this time the building personnel stated the agency Owner stated he would call her right back. Approximately one minute later the building personnel received a return call and stated that the agency Owner wanted to talk to the Surveyor. During a telephone interview on 6-17-26 at 11:21 am the agency owner stated that he was out of town until next Wednesday and would not be able to come to the agency. The Surveyor then asked the Owner who had the agency put in place to allow the Surveyor entry. The Owner stated himself, Administrator/Supervising Nurse, Alternate Administrator or the Alternate Supervising Nurse. The Surveyor then requested that the Owner call the Administrator or Alternate Administrator to be available for the survey and let the Surveyor into the agency. The agency Owner stated the Administrator/Supervising Nurse would not be available to allow surveyor entry within 2 hours of arrival and the Alternate Administrator was currently in Dallas, Texas. At this time the Surveyor asked about the Alternate Supervising Nurse. The Owner stated he would try to call the Alternate Supervising Nurse. During a return call from the agency Owner on 6-17-26 at 11:42 am the Owner stated that he had tried to call the Alternate Supervising Nurse. However, The Alternate Supervising Nurse was not answering the calls. The Owner was made aware that the Surveyor would wait the 2 hours from arrival (11:15 am) and the Owner stated that if the Alternate Supervising Nurse returned his call he would call and let the Surveyor know. During an observation on 6-17-26 at 11:53 am the communal building personnel lead the Surveyor to the agency’s unmarked agency office door. There was no activity at the office. The Surveyor went to the entry lobby of building 12:15pm , no return call from agency staff or agency Owner. The Surveyor was noted in entry Lobby of building at 1:15 pm , no return call from agency staff or agency Owner. At 2:11 pm on 6-17-26 the Surveyor returned to the communal lobby area and spoke to the building personnel at desk. The building personnel stated that no one from the agency had arrived at the agency office but that she would go back and check for the Surveyor. The communal desk personnel returned and stated that no one from the agency was at the agency office. At this time the surveyor left the agency building. The surveyor was unable to conduct the recertification survey and unable to verify if agency had patients due to the Administrator or a pre-designated person not being available during all operating hours to the Surveyor to allow entry into the agency and to start the recertification survey to verify compliance with the regulations. The Surveyor sent the agency via email the letter of inability to conduct a federal survey on 6-17-26 at 5:01 pm.”