A Nurses Touch Home Health

“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, observation, and interview, the HHA failed to report possible neglect of a patient by the PAS Agency 1 to HHSC in 1 out of 5 patients (Patient 2) investigated, in that: the HHA nurses noticed Patient #2 had been living in unclean environmental conditions and appeared to not be getting all the PAS services from PAS Agency 1. This failure could place the agency’s patient at risk for continued neglect by PAS Agency 1 if this went unreported and uninvestigated, along with placing the patient at risk of infection for living in a soiled environment. Findings included: Record review of Patient 2’s electronic health record revealed a document titled, “Patient Communication,” dated 7/8/25, which read, “Called [PAS Agency 1] for patient care that is not being performed. Left message for […] the case manager to discuss change in providers and need for improved services. Awaiting call back.” The note was signed by the Administrator. This was the only record of contact with PAS Agency 1 in the Patient’s record. In an interview with the Administrator at 3:36 PM on 8/4/25 , the Administrator stated that Patient 2 was a “really tough case”. She elaborated that he lived in poor housing conditions with no one to take care of him. She stated nurses had found him in soiled clothes, laying in dirty sheets, with food and bugs in the environment. She stated they originally provided home health aide services to assist him with cleaning and personal care, but then the HHA helped refer him for PAS services from PAS Agency 1 . She stated Patient 2 made the comment to one of the nurses that the Attendant 1 was not showing up for all her hours, and it was then that the Administrator called PAS Agency 1 and asked them to do a supervisory visit and reevaluate for more hours. The Administrator could not recall exactly when this occurred or which nurse reported it to her. Surveyor asked Administrator if she had reported PAS Agency 1 to the state for Patient Neglect. She stated she did not. She stated that they did make an APS repo rt due to poor living conditions and inability to care for himself when the patient first started care with the Agency, around October 2024. She stated that the case was closed because APS ruled that he was in his “right mind”, and this was how he “chose to live”. She stated Patient 2’s family member had been trying to get him to live in a nursing home, but that the patient refused. She stated they then took him on as a patient and provided Home Health Aide services along with Nursing Services. In an observation in Patient 2’s home during a home visit on 8/5/25 at 11:15 AM, the Surveyor observed Patient 2’s living conditions while the patient received a visit from NP A, a wound-care nurse practitioner employed by Wound Care Agency 1. The patient lived in an apartment with two roommates, who were not home at the time. Attendant #1 was on the front porch and greeted NP A and surveyor and told them to enter the home. Patient 2 was found in a bedroom on a hospital bed with a pull bar. Patient 2’s clothes had visible stains on them and two empty urinals were in his bed. The sheets had slid halfway off the bed and had crumbs on them. Flies and water bugs were seen flying and crawling around the room. When NP A provided wound care, several flies flew close to the wound and landed on it, and NP A had to swat them away and clean the wound . A history of stroke left Patient 2 with difficulty communicating. He grunted some answers to the NP A’s questions but did not engage in conversation when the Surveyor attempted to ask him questions. In an interview with NP A at 11:10 AM on 8/5/25, NP A stated she had been providing wound care to Patient 2 since April 2025. She stated that the patient’s environment was “dirty” but that he did have a neighbor who helped him personal tasks, and that she had seen this neighbor consistently at her visits the last couple weeks. Surveyor asked if this was the neighbor employed by PAS Agency 1, but NP A stated she did not know. She stated that the neighbor helps him clean, do laundry, and take him to appointments. She was unable to recall if the patient’s environment had been significantly worse in the time period of May – early July (the time when the HHA suspected PAS Agency 1 was not providing all service hours). She stated that the environment was difficult to work in, that there were always bugs in the home, and it was difficult to keep the wound free from infection. NP A stated they usually only brought what supplies they would need and left everything else in the car. She stated she tried to get the patient to wear socks over his bandage, because he frequently dragged his bandaged wound on the ground outside and it became very dirty, but he had refused. She stated that they “do their best for him”. After the home visit on 8/5/25, at 11:50 AM, the Surveyor asked the neighbor on the porch if she was the provider providing services for Patient 2 under PAS Agency 1. She confirmed that she was. She stated she worked 3 hours a day providing care for Patient 2. She stated she did tasks like laundry, purchasing food, helping clean his room, and taking him to appointments . She stated that he was able to clean himself when he soiled himself. The Surveyor was not investigating the PAS Agency or the PAS Attendant at this time, but rather the HHA’s failure to report possible neglect by another agency. In an interview with the Administrator at 2:45 PM on 8/5/25, the Surveyor showed the Administrator the note found in Patient 2’s record that showed the Administrator called the PAS agency on July 7, 2025. She confirmed that was correct. The Administrator stated that they did not report PAS Agency 1 to HHSC for neglect because they felt the problems resolved after she called the PAS Agency 1. The nurses reported that his environment was cleaner, and they started seeing the PAS provider around the patient’s house more. She stated she did not think it was neglect at the time, but rather a bad match with the PAS provider, who was a neighbor/friend. She stated that Patient 2 was known to refuse services if given the option and would say he could do things by himself even when he could/would not. She stated they were not sure if the PAS provider was not doing her job, or if she was attempting and Patient 2 was declining and she was not being “firm enough”. In an interview with the Administrator at 9:50 AM on 8/6/25, the Administrator elaborated on the timeline of events. She stated that from admission in October of 2024 to April of 2025 they were providing Home Health Aide services to him, but they referred him for PAS services, which began in April of 2025, and they stopped regular Home Health Aide visits at this time. However, the nurses continued to report that Patient 2 was being found in soiled clothes and linens, and they would find him in the same clothes when they came several days later. Per Administrator, it seemed that Patient 2 was not receiving the PAS services as needed. She stated during this time that they bought him new clothes and collected donations for him. She stated they got him set up with transportation services in May, but due to him being so dirty, she sent an aide out to bathe him and dress him in new clothes for his appointment, and did not bill for it. She stated that LVN 1 reported that she was at Patient 2’s home while the PAS provider was supposed to be there, and LVN reported that the PAS provider never came. She stated that it was that, along with the comment from Patient 2 that Attendant 2 was not coming for all the hours, that urged her to call PAS Agency 1 and find out what was happening. She confirmed she made the call on 7/8/25 and requested they do a supervisory visit and reevaluate hours. The Surveyor asked how not reporting the failure of PAS Agency 1 to provide care affected patient care. The Administrator stated that it did not, because her agency sent out home health aides to “pick up the slack” during this time to ensure the patient was cared for. She stated the nurses went above and beyond to care for this patient. Record review of the document titled, “Intake Report Adult Protective Services”, revealed a case report involving Patient 2 with allegations of medical and physical neglect. This report was made on 11/14/2024 and the Reporter is listed as the Administrator. Of note, this document is just the report, and there are no findings included. The report read, in part, “Describe concerns about the alleged victim’s hygiene and negative effects: very poor hygiene, foul odor, home health aide performs 3 times per week, patient is saturated in urine and bowel when aid returns for visit, he is wearing the same clothes form previous visit.” Of note, this report was filed when the HHA first began caring for the patient and providing skilled nursing and home health aide services. No report was made in the time of April – June 2025, which was when the HHA suspected possible neglect of PAS Agency 1. Record review of the agency policy titled, “Abuse, Neglect, Exploitation, and Fraud,” dated 10/2021, read in part, “Any agency staff 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 (Within 24 hours) to the Agency and appropriate state authorities in accordance with state law.””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 722 of 815 assessments processed for the time-period reviewed of 03/09/2024 to 03/09/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: Review of the HHA Error Summary Report for the time period of 03/09/2024 to 03/09/2025 identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 722 assessments and the percentage of assessments with this error was 88.59% of assessments completed by the Agency. In an interview completed with the Administrator on 3/12/25 at 10:13 AM, the surveyor showed Administrator the “Home Health Error Summary” report which indicated that 722 OASIS assessments were late by the agency. The Surveyor asked the Administrator why assessments were submitted late to OASIS. Administrator reported that they had an issue with not having enough nurses to keep up with documenting assessments and so they were consistently late on transmitting assessments until they were able to hire 2 new nurses. The Surveyor asked how submitting data late to OASIS impacted client care. The Administrator reported that late documentation impacts client care by decreasing care coordination for the client. Review of the Agency’s policy titled “OASIS Transmittals,” dated 10/2021, revealed that “although CMS regulations allow for a 30 day ‘lock and load’ period, it is our Agency’s policy to ‘lock and load’ OASIS (data) within 7 days of assessment completion.””