Prestonwood Home Healthcare LLC

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to immediately report allegations of physical abuse by an agency employee to HHSC within 24 hours for 1 of 9 clients reviewed (Client #1), in that: The agency had cause to believe that PROV A had physically abused Client #1 and failed to report the allegation to HHSC. This failure placed the agency’s clients at risk of further abuse by agency employees. Findings included: Review of agency’s complaint log did not reveal any report of the client’s complaint of physical abuse by PROV A. No internal agency investigation was conducted or documented. Review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health agencies for the State of Texas) on 8/11/2026, revealed no self-reported incidents regarding Client #1 were received by the date of investigation on 8/12/2026. Record review of the Incident Investigation Worksheet for Intake #1110875 in TULIP indicated physical abuse allegation was received by HHSC on 8/10/2026 at 4:00 PM. During an interview with INS on 8/11/2026 at 3:00 PM, INS stated that Client #1 claimed PROV A was driving recklessly and placed the client into PROV A’s personal vehicle to go to the pharmacy. INS further revealed that PROV A forcibly grabbed Cleint#1 arm while Client #1 was trying to get out of the car. During an interview with Client #1 she stated that PROV A grabbed her by the arm and did not allow her to get out of the vehicle. Client #1 then attempted to jump out of the moving vehicle due to not feeling safe. Around 4:30 PM Client #1 called the agency and reported the occurrence to OFM A. Record review of agency documentation did not reveal any documentation that the agency reported these allegations to HHSC within 24 hours of being made aware of the allegations. Further record review revealed no documented evidence on an internal complaint investigation. An interview with OFM A was conducted on 8/13/2026 at approximately 11:30 AM. The Surveyor asked OFM A what she recalled about the incident. OFM A stated that she did receive a call from Client #1. She believed it to be a routine complaint and therefore did not report it to OFM B who was responsible for handling internal investigations within the agency. A joint interview with the Administrator and Alternate Administrator was conducted on 8/14/2026 at approximately 11:30 AM the Administrator and Alternate Administrator were presented with the above findings. The Surveyor asked why this complaint was not called into the State/HHSC. The Administrator stated that administration had not been notified OFMA nor OFM B of the allegation. The Administrator stated that OFM B was responsible for all of the internal investigations of complaints, and if he had been notified, the allegation would have been internally investigated and reported to HHSC. Ultimately, the Administrator admitted responsibility for what happens within the agency for the safety of the agency’s clients. Review of the agency’s policy titled, “Abuse, Neglect, and Exploitation”, dated 1/13/2018, revealed in part… “If the Agency has cause to believe that a client served by the Agency has been abused, neglected, or exploited by an Agency employee, the Agency must report the information immediately, meaning within 24 hours, to: …Texas Health and Human Services (HHS)...””

“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, observation, and interview the agency failed to ensure that the individualized plan of care (POC) included the required elements in three of three patient records reviewed, in that: for (Patients # 1, 2, and 3) the POC failed to include all pertinent diagnoses, the patient’s psychosocial status (refers to the interaction between an individual’s thought, emotions, behavior, their relationships, culture, and society), neurological status (includes assessing mental status, nervous system, movement status, reflexes, sensations), activities permitted, all medications, and safety measures to protect against injury. The failure placed the patient at increased risk of having poor physical health and safety outcomes, increased mental health decline, and social isolation due to not having a detailed plan of care. Findings include: Patient # 1: Review of Patient # 1’s clinical record revealed a POC with a SOC date of 11/25/2025 and a treatment period of 11/25/2025 to 05/23/2026. Review of the POC revealed that RN B signed and dated the POC on 12/01/2025. Continued review of the POC revealed that there was no assessment for psychosocial status, neurological status, or safety measures to protect against injury included in the POC. Further review of the POC revealed that it included orders for SN visits one time a week for nine weeks. Review the Patient # 1’s medication list revealed the patient used oxygen continuously to assist with maintaining consistent oxygen levels in the blood (which required safety measures i.e., no smoking, keeping oxygen tanks away from open flames). Continued review of Patient # 1’s record revealed an “Approval Referral For Medical Care” form dated 11/24/2025 from the client’s payor source (Payor Source A). Review of the approval form revealed that the agency was authorized to provide seven to six hours of home health aide (homemaker services) to assist with activities of daily living (household tasks, i.e., laundry, cleaning; personal care tasks i.e., assisting with bathing and shaving) and SN visits for oversight of homemaker/home health aide services. Patient # 2: Review of Patient # 2’s clinical record revealed a POC with a SOC date of 11/27/2025 and a treatment period of 11/27/2025 to 05/25/2026. Review of the POC revealed that RN B signed and dated the POC on 12/04/2025. The POC included a primary diagnosis of congestive heart failure (a condition where the heart muscle cannot pump enough blood to meet the needs of the body, effectively). Continued review of the POC revealed that there was no assessment of the patient’s psychosocial status or neurological status included in the POC. Further review of the POC revealed that it included orders for SN visits one time a month for eight months. Continued review of the record revealed that Patient # 2 had a diagnosis of stroke (a neurological condition that occurs when blood flow to a part of the brain is interrupted by blood vessel bursting or getting blocked; the interruption causes brain cells to die due to lack of oxygen, this condition requires safety measures) with right side paralysis. Continued review of Patient # 2’s record revealed an “Approval Referral For Medical Care” form dated 11/25/2025 from the client’s payor source (Payor Source A). Review of the approval form revealed that the agency was authorized to provide 12 to 16 hours of home health aide (homemaker services) to assist with activities of daily living (household tasks, i.e., laundry, cleaning; personal care tasks i.e., assisting with bathing and shaving) and SN visits for oversight of homemaker/home health aide services. Patient # 3: Review of Patient’s # 3’s clinical record revealed a POC with a SOC date of 10/28/2025 and a treatment period of 10/28/2025 to 04/25/2026. Review of the POC revealed that RN A signed and dated the POC on 10/28/2025. Continued review of the POC revealed that there were no diagnoses included, psychosocial status, activities permitted, any medications, or safety measures to protect against injury included in the POC. Further review of the POC revealed that it included orders for SN visits one time a month for eight months and home health aide (homemaker) services for 10 hours weekly to assist with activities of daily living (household tasks, i.e., laundry, cleaning; personal care tasks i.e., assisting with bathing and shaving). During a home visit, observation and interviews with Client # 3 and CG A on 03/24/2026 at 9:30 AM, the surveyor asked Client # 3 his age and birth date. Client # 3 stated an incorrect age and the correct date of birth. The surveyor pointed to (CG A) and asked who she was. The surveyor observed that Client # 3 could not identify (CG A) without her prompt. During an interview with RN B on 03/24/2026 at 1:40 PM, the surveyor asked how long RN B had worked for the agency. RN B stated that she started working for the agency early last year (2025). The surveyor asked RN B to explain her process for conducting patient assessments. RN B stated that she called the patient. She asked if the patient had dogs. When she arrived at the home she explained the reason for the admission. She obtained their consent to receive services from the agency. She provided the admission paperwork and discussed patient rights information. She stated that she informed the patient if they have a complaint, they could call the agency and the state. She left copies of the paperwork with the patient. She had them sign an authorization to keep the doctor informed and updated. She stated that the last thing that she did was the OASIS assessment (is a group of standard data elements home health agencies include in their comprehensive assessment, to collect and report quality data to CMS) and comprehensive assessment information. She asked about their medications and conducted a head-to-toe assessment of the patient. The surveyor asked if RN B completed the plan of care. RN B stated that the plan of care populated (patient information was filled in) from the OASIS assessment. The surveyor asked if she completed the OASIS for the skilled and non-skilled patients the same. RN B stated that she did not know there was any difference. The surveyor asked why the plan care was not completed with all the required elements (psychosocial status, neurological status, and safety measures) for Clients # 1 and 2. She replied, “I can’t answer that I don’t have the information in front of me.” She stated if the patient had not had a stroke and there was nothing to address, then there would be nothing documented under that area. “I only see them one time, to do the initial assessment.” The surveyor asked if the nurse did supervisory visits for the home maker/home health aide caregiver. She replied, “No, I just do admission.” During an interview with RN A on 03/24/2026 at 1:50 PM the surveyor asked how long RN A had worked for the agency. RN A stated that she started in September of 2025. The surveyor asked if RN A remembered doing the initial assessment for Client # 3. RN A stated that she did remember doing the initial visit and (OASIS) initial assessment with Client 3. The surveyor asked what RN A remembered about Client # 3. RN A stated that he lived with family members, he had dementia (memory loss, confusion, and behavioral changes that interfere with daily life) and high blood pressure. RN A stated that his family member was his provider (paid caregiver). The surveyor asked if there were any safety concerns that she remembered. RN a stated that she remembered that Client # 3’s family member said he liked being at home, so there wasn’t much of a risk with falls. The surveyor asked if the client had any medication. She stated that he did have medication, but she did not remember what kind of medication because she did not have access to the record at that time. The surveyor asked RN A to explain her process for conducting patient assessments. RN A stated that she introduced herself, explained the purpose of the visit, answered questions, and explained the reason for the home health referral. RN A stated that during initial assessment visits with patients she asked them if they approved of being admitted to the agency. RN A completed a health assessment and reviewed their health history. The surveyor asked if RN A completed the OASIS and comprehensive for the skilled and non-skilled patients the same. RN A stated that the assessments were completed the same, and that she did not know anything about doing a non-skilled assessment differently. The surveyor asked if RN A remembered doing the OASIS assessment for Client # 3. RN A stated that she did remember doing the initial visit and initial assessment with Client #3. The surveyor reviewed the findings of the OASIS and plan of care not being completed with all required elements (no diagnosis on POC, no medications listed on POC, no psychosocial status, no safety measures, and no activities permitted on POC). The surveyor asked why OASIS and POC did not include the required elements. RN A stated that it sounded like to her that she got interrupted and just submitted it incomplete.” During an interview with the Admin/DON and Alt Admin on 03/24/2026 at 2:44 PM, the Surveyor reviewed the findings. The surveyor asked what processes the agency had in place to ensure that RNs had completed the OASIS and comprehensive assessment with all required elements (so that the POC included all required elements). Admin/DON stated that there was an OASIS check (in the software), the software would not let the RN submit the OASIS if they had not completed it. Admin/DON stated that the RN would notify the agency if the OASIS did not submit. Admin/DON stated that she did not know that the OASIS for Client # 3 and the POC (s) for Clients # 1, 2, and 3 did not include the required elements; and that she would have to look at them. Admin/DON stated that she was responsible for ensuring OASIS assessments and POC were completed. Review of agency policy titled, “Plan of Care” last reviewed 01/01/2026 read in part, “Purpose [:] To ensure that care provided is appropriately planned in a timely manner to meet the patients/clients. specific needs and problems... Policy [:] I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs… A. A registered nurse (RN) initiates the Plan of Care for skilled nursing care and for personal hygiene/activities of daily living care… III. Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the Plan of Care. The individualized Plan of Care will indicate if the patient/client has an advance directive(s) and if so, what type(s) of advance directive(s) exists. If the patient does not have an advance directive, this should also be listed on the individualized Plan of Care. The individualized Plan of Care must also specify the patient/client and caregiver education and training. A. The individualized Plan of Care must include the following: 1. All pertinent diagnoses; 2. The patient’s/client’s mental, psychosocial, and cognitive status; 3. The types of services, supplies, and equipment required; a. The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care. 4. The frequency and duration of visits to be made; 5. Prognosis; 6. Rehabilitation potential; 7. Functional limitations; 8. Activities permitted; 9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury; 12. A description of the patient’s/client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors. 13. Patient/client and caregiver education and training to facilitate timely discharge; 14. Patient/client-specific interventions and education; 15. Measurable outcomes and goals identified by the Agency and the patient/client; 16. Information related to any advance directives; and 17. Any additional items the Agency or physician or allowed practitioner may choose to include…””