Restore Wellness Home Care

“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: Condition of Participation: Skilled Professional Services (484.75) is not met Based on record review and observation (on-site visit), the agency failed to be primarily engaged in providing the following care and services: nursing services; physical therapy; occupational therapy; and speech-language therapy, physician, and medical social services who provide services to patients, directly or under arrangement, participated in coordination of services in a manner that was consistent with accepted standards of practice. The Agency’s skilled professionals must assume responsibly for patient care and on-going interdisciplinary assessment of the patient, in that the agency failed to provide a surveyor entry to the Agency to begin a survey during regular business hours to conduct a survey on 8/21/26. (Refer to G 706),”

“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: Condition of Participation: Organization and Administration of Services 484.105 is not met The Adm failed to manage the day-to-day operations of the Agency, in that the Agency failed to provide a surveyor entry to the Agency to begin a survey during regular business hours, to conduct a survey on 8/21/2026. (Refer to G 948) The Administrator or a pre-designated person failed to be available during all operating hours, specifically, the Agency failed to provide a surveyor entry to the Agency to begin a survey during regular business hours, to conduct a survey on 8/21/2026. (Refer to G 956) The Agency failed to furnish skilled nursing services and at least one other therapeutic service) physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide in a place of residence used as a patient’s home. The Agency failed to provide at least one skilled nursing or other therapeutic service directly and failed to provide a second service under arrangement with another agency or organization. The Agency failed to provide a Surveyor entry to the Agency to begin a survey during regular business hours, to conduct a survey on 8/21/2026.(Refer to 982)”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: The Agency failed to furnish skilled nursing services and at least one other therapeutic service) physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide in a place of residence used as a patient’s home. The Agency failed to provide at least one skilled nursing or other therapeutic service directly and failed to provide a second service under arrangement with another agency or organization. The Agency failed to provide a Surveyor entry to the Agency to begin a survey during regular business hours, to conduct a survey on 8/21/2026. Findings: Record review of web based licensure system Texas Unified Licensure Information Portal (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) on 8/21/2026, revealed the agency listed an Administrator [ADM A], an Alternate Administrator [ADM B], the agency address and phone number, and the operating hours: 9:00 a.m. to 5:00 p.m. (Monday through Friday). The agency’s category was listed as home health. TULIP showed the agency had an active license with an expiration date of 9/30/2027. Observation on 8/21/2026 at 10:15 a.m. revealed the agency’s address was in a private home in a residential area. There was no visible agency identification on the outer door. The surveyor knocked and rang the doorbell with no response. On 8/21/2026 at 10:30 a.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.” On 8/21/2026 at 10:57 a.m. the surveyor sent an email to the email addresses listed in TULIP for the agency administrator (ADM A), alternate administrator (ADM B), director of nurses (DON), and the assistant director of nurses (ADON). On 8/21/2026 at 10:57 a.m. the surveyor received notice that the emails for ADM A, ADM B, and DON were “undeliverable.” On 8/21/2026 at 11:20 a.m. the surveyor sent another email to the assistant director of nurses (ADON) listed in TULIP. On 8/21/2026 at 12:15 p.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.””

“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 record review and observation (on-site visit), the agency failed to ensure continual involvement of all skilled professional staff (nursing services; physician services; physical therapy; occupational therapy; and speech-language therapy services; medical social worker; home health aides) involved in a patient’s plan of care from the initial assessment through discharge and their interactions with each other to meet the patient’s needs. This failure demonstrated a lack of administrative leadership, ineffective or improper management of the agency’s operations and oversight that could negatively impact patient care and protect the rights and safety of agency patients. This failure also placed the Agency out of compliance with regulatory requirements. Findings: Record review of web based licensure system Texas Unified Licensure Information Portal (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) on 8/21/2026, revealed the agency listed an Administrator [ADM A], an Alternate Administrator [ADM B], the agency address and phone number, and the operating hours: 9:00 a.m. to 5:00 p.m. (Monday through Friday). The agency’s category was listed as home health. TULIP showed the agency had an active license with an expiration date of 9/30/2027. Observation on 8/21/2026 at 10:15 a.m. revealed the agency’s address was in a private home in a residential area. There was no visible agency identification on the outer door. The surveyor knocked and rang the doorbell with no response. On 8/21/2026 at 10:30 a.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.” On 8/21/2026 at 10:57 a.m. the surveyor sent an email to the email addresses listed in TULIP for the agency administrator (ADM A), alternate administrator (ADM B), director of nurses (DON), and the assistant director of nurses (ADON). On 8/21/2026 at 10:57 a.m. the surveyor received notice that the emails for ADM A, ADM B, and DON were “undeliverable.” On 8/21/2026 at 11:20 a.m. the surveyor sent another email to the assistant director of nurses (ADON) listed in TULIP. On 8/21/2026 at 12:15 p.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.””

“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 observation (on-site visit), the agency failed to ensure the Administrator was actively involved and responsible for all day-to-day operations of the home health agency in that: The agency failed to provide a surveyor entry to the Agency to begin a survey during regular business hours, to conduct a survey on 8/21/26. This failure demonstrated a lack of 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. This failure also placed the Agency out of compliance with regulatory requirements. Findings: Record review of web based licensure system Texas Unified Licensure Information Portal (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) on 8/21/2026, revealed the agency listed an Administrator [ADM A], an Alternate Administrator [ADM B], the agency address and phone number, and the operating hours: 9:00 a.m. to 5:00 p.m. (Monday through Friday). The agency’s category was listed as home health. TULIP showed the agency had an active license with an expiration date of 9/30/2027. Observation on 8/21/2026 at 10:15 a.m. revealed the agency’s address was in a private home in a residential area. There was no visible agency identification on the outer door. The surveyor knocked and rang the doorbell with no response. On 8/21/2026 at 10:30 a.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.” On 8/21/2026 at 10:57 a.m. the surveyor sent an email to the email addresses listed in TULIP for the agency administrator (ADM A), alternate administrator (ADM B), director of nurses (DON), and the assistant director of nurses (ADON). On 8/21/2026 at 10:57 a.m. the surveyor received notice that the emails for ADM A, ADM B, and DON were “undeliverable.” On 8/21/2026 at 11:20 a.m. the surveyor sent another email to the assistant director of nurses (ADON) listed in TULIP. On 8/21/2026 at 12:15 p.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.””

“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 record review and observation (on-site visit), the agency failed to ensure that the administrator or pre-designated person was available during all operating hours. This failure caused the HHSC (Health and Human Services Commission) surveyor to be unable to enter the agency to determine whether core services: nursing services, physician services, physical therapy, occupational therapy, and speech-language therapy services, medical social services, and home health aide services were delivered as required. Findings: Record review of web based licensure system Texas Unified Licensure Information Portal (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) on 8/21/2026, revealed the agency listed an Administrator [ADM A], an Alternate Administrator [ADM B], the agency address and phone number, and the operating hours: 9:00 a.m. to 5:00 p.m. (Monday through Friday). The agency’s category was listed as home health. TULIP showed the agency had an active license with an expiration date of 9/30/2027. Observation on 8/21/2026 at 10:15 a.m. revealed the agency’s address was in a private home in a residential area. There was no visible agency identification on the outer door. The surveyor knocked and rang the doorbell with no response. On 8/21/2026 at 10:30 a.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.” On 8/21/2026 at 10:57 a.m. the surveyor sent an email to the email addresses listed in TULIP for the agency administrator (ADM A), alternate administrator (ADM B), director of nurses (DON), and the assistant director of nurses (ADON). On 8/21/2026 at 10:57 a.m. the surveyor received notice that the emails for ADM A, ADM B, and DON were “undeliverable.” On 8/21/2026 at 11:20 a.m. the surveyor sent another email to the assistant director of nurses (ADON) listed in TULIP. On 8/21/2026 at 12:15 p.m. the surveyor attempted to call the phone number listed in TULIP. The message on the call stated, “the number was not in service.””

“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 observations and record reviews the agency failed to ensure an administrator, or a pre-designated person was available during all operating hours. This failure resulted in the inability of the surveyor to conduct a recertification and complaint investigation to verify the agency’s compliance with the Federal Regulations for Home Health Agencies, which could lead to poor quality care and patient dissatisfaction with services provided by the agency. Findings: Record review of 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) on 11/20/2025 revealed the agency’s location, email address, phone number, and names of the Administrator and Alternate Administrator. The agency’s phone number had a notation of “no longer in service.” There was no evidence of an alternate contact number for the agency, Administrator, or Alternate Administrator. TULIP also contained an active state license effective 9/30/2024 with an expiration date of 9/30/2027 and operating hours 9am to 5pm Monday through Friday. The last application in TULIP was dated 9/5/2024 for a “Name of Owner” change. Record review of IQIES (an online program by CMS for managing survey and certification data for healthcare providers) on 11/20/2025 revealed a first attempt by a surveyor on 5/6/2025 for a recertification, relicensure survey and investigation of complaint intakes 555727, 404014 and 387247. Record review of the HHA Activity Report in IQIES on 11/20/2025 revealed the last OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) submissions were dated 1/29/2025. 11/20/2025 at 10:07am the surveyor arrived at the agency address noted in TULIP, located in a residential home and observed a sign posted on the front door from a Realtor. The sign read, “This is a bank-owned property. No trespassing or entry permitted. Violators will be prosecuted. This home is listed for sale…” On the doorstep the surveyor observed a box of unopened mail from the postal service. The entryway did not contain a sign with the name of the home health agency or contact information for the agency. The lights were off at the agency, and no one answered the door when the surveyor rang the doorbell. 11/20/2025 at 10:29am the surveyor called the phone number listed for the agency in TULIP and received a voice recording stating “The number you are dialing is not in service at this time.” 11/20/2025 at 11:08am the surveyor sent an email to the Administrator’s/agency’s email address listed in TULIP. The surveyor wrote in the e-mail that she was at the agency and requested entry. The surveyor informed the home health agency via email of the 2-hour window to allow the surveyor entrance into the agency to avoid enforcement actions against the agency. The surveyor included in an attachment “Memo 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services” with the date and time of the attempted contact with the agency. 11/20/2025 at 11:08am the surveyor received a message via the state’s email provider which read “Your message couldn’t be delivered. The Domain Name System reported that the recipient’s domain does not exist.” 11/20/2025 at 11:35am The surveyor did not locate any active websites, alternate addresses or contact numbers, for the agency on the internet. 11/20/2025 at 11:50am The surveyor searched the Realtor’s website and located the residential home address listed in TULIP for the agency. The home was “pending” sale, and the listing was last updated on 11/15/2025. 11/20/2025 at 12:07pm the surveyor left the address of the agency.”