Steden Home Health Services

“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 interview the agency failed to report an allegation of neglect to the Texas Health and Human Services (HHSC) the state’s authorities for investigating neglect of a patient for 3 of 3 (#1, #2, & #8) patients in that: Patient #1 fell on 02/17/2025, with PVD D present and sustained a broken hip. Patient #2 fell on 05/13/2025 and sustained minor injuries (reported by the facility to the agency) and the agency did not report this. Patient #8 fell on 04/28/2023, with PVD C present and sustained three broken ribs and a broken collar bone. These failures to report the allegation of neglect to the appropriate authorities in accordance with state law placed patient #1, #2, and #8 at risk of further harm. Findings include: Patient #1 Record review of Patient #1’s CR showed a SOC of 10/10/2024. ISP provided for the certification period of 10/10/2024-10/10/2025, was signed and dated on 10/03/2024 by OC/ PAS Supervisor. Principal Diagnosis was Vascular Dementia with behavioral Disturbances, (a condition that affects the brain’s blood supply is compromised, leading to cognitive and behavioral changes). Authorization for 13.5 hours per week, 2 days Friday for 5.5 hours and Saturday 6 hours, to help with bathing, toileting, laundry, dressing, transfers, shopping, meal preparation, walking, cleaning, and assist with self- administration of medications. An additional ISP, signed and dated on 01/09/2025, with an increase in weekly hours and days to include Tuesday for 3 hours, Friday for 7 hours, and Saturday for 8 hours for a total of 18 hours per week. Record review of document titled; “Incident Report; January- March 2025” revealed an incident on 02/17/2025 regarding Patient #1. Incident was listed as “fell-broke hip” and resolution “hospitalized”. Record review of an additional agency document titled, “Incident Report” revealed, the incident was reported to agency on 02/17/2025 at 9:55 A.M., by PVD D. Document revealed that Patient #1 had a slip/fall. The document indicated that the agency’s DON, OC, and FM #1 was contacted about the incident. No further details regarding how the incident occurred was documented. Record review of agency personnel records, specifically PVD D personnel record revealed, date of hire 10/10/2024. A document titled “Policy Acknowledgement Form” …read in part... I have been given the opportunity to review all agency administrative and clinical policies. I understand and will comply with all Agency Services policies… and this document was signed and dated 10/10/2024 by PVD D. Record review of TULIP, an online system for submitting long-term care licensure applications and health care regulation Architectural Review requests, did not reveal any self-reported intakes or PIRs from agency related to Patient #1 and the allegation of neglectful supervision. On 07/09/2025 at or about 1;45 P.M. to contact FM #1. Surveyor was unable to reach, and message was left. On 07/09/2025 at or about 11:00 A.M. an interview with OC confirmed that she received the report of the incident regarding Patient #1 and logged into the Incident Report log. OC stated that she informed the DON of the incident. OC stated that she was not aware that the agency was supposed to report the fall or any other incidents like that to the designated authorities. On 07/09/2025 at or about 11:15 A.M. an interview with the agency’s DON confirmed that she was informed about the incident. The DON stated that the investigation was done and didn’t think it was supposed to be reported. The DON did not respond to why the incident was not reported to the proper authorities. The DON stated that she did not know any further details than what she was told. The DON stated that she and the Admin were responsible for ensuring that the agency’s policies were followed. The DON declined to respond to surveyor’s question why the policy was not followed. The Admin was present during the DON’s surveyor and stated that she was unable to stated why the DON declined to answer further questions about the agency’s policies not being followed. On 07/09/2025 at or about 11:30 A.M. an interview with the Admin confirmed that the agency’s office received the incident report on 02/17/2025. The Admin stated that she did not know why the incident was not reported per agency policy or state statues. The admin stated that she usually leaves clinically issues to the DON. Admin confirmed that this practice places the agency’s other client at risk for potential further neglect. Admin stated that she was aware that the incidents should have been reported to HHSC and thought the DON had done so. Admin confirmed that she was ultimately responsible for ensuring all agency policies were followed and she expected all staff to follow the agency’s policy. The Admin stated that the potential impact on the agency’s patients was that they could be at risk for further neglect. On 07/10/2025 at or about 12:20 P.M. an interview with the PVD D revealed that she reported the fall for Client #1 to the agency office, specifically OC. During home observation on 07/102025, Client #1 was unable to answer questions appropriately. There was no family present during the visit. Patient #2 Record review of Patient #1’s CR included a form titled “Home Health Certification and Plan of Care” (POC) for the certification period of 04/08/2025-06/06/2025 that revealed a SOC date of 04/08/2025. The POC included diagnoses of: Type 2 diabetes mellitus (chronic condition characterized by high blood sugar levels due to insulin resistance), essential (primary) hypertension (develops when blood flows through your arteries at higher-than-normal pressures), and schizoaffective disorder bipolar type (mental health condition that combines symptoms of schizophrenia, such as hallucinations and delusions, with the mood disorder symptoms of mania- extreme mood swings). Orders included: SN visits 1w9w beginning week of 06/07/2025 and prn visit 1-2 for problems. SN/PT/OT to assess. Record review of document titled; “Incident Report; April- June 2025” revealed an incident on 05/13/2025 regarding Patient #2. Incident was listed as “fell-minor injury” and resolution “fall prevention education”. Record review of an additional agency document titled, “Incident Report” revealed, the incident was reported to agency on 05/13/2025 at 10:02 A.M., that it alleged occurred on 05/11/2025 reported by assisted living staff. The document revealed that Client #2 had a slip/fall. The document indicated that the agency’s DON, and OC was contacted about the incident. No further details regarding how the incident occurred was documented. Record review of TULIP, an online system for submitting long-term care licensure applications and health care regulation Architectural Review requests, did not reveal any self-reported intakes or PIRs from agency related to Patient #2 and the allegation of neglectful supervision. On 07/09/2025 at or about 11:00 A.M. an interview with OC confirmed that she received the report of the incident regarding Patient #2 and logged into the Incident Report log. OC stated that she informed the DON of the incident. OC stated that she was not aware that the agency was supposed to report the fall or any other incidents like that to the designated authorities. On 07/09/2025 at or about 11:15 A.M. an interview with the agency’s DON confirmed that she was informed about the incident. The DON stated that the investigation was done and didn’t think it was supposed to be reported. The DON did not respond to why the incident was not reported to the proper authorities. The DON stated that she did not know any further details than what she was told. The DON stated that she and the Admin were responsible for ensuring that the agency’s policies were followed. The DON declined to respond to surveyor’s question why the policy was not followed. The Admin was present during the DON’s surveyor and stated that she was unable to stated why the DON declined to answer further questions about the agency’s policies not being followed. On 07/09/2025 at or about 11:30 A.M. an interview with the Admin confirmed that the agency’s office received the incident report on 02/17/2025. The Admin stated that she did not know why the incident was not reported per agency policy or state statues. The admin stated that she usually leaves clinically issues to the DON. Admin confirmed that she was ultimately responsible for ensuring all agency policies were followed and she expected all staff to follow the agency’s policy. On 07/10/2025 at or about 10:45 A.M. the surveyor performed a skilled nurse visit observation for Patient #2. Patient #2 was pleasant and uncooperative. He was unable to answer questions appropriately. The assisted living staff member that was present stated that he was not on shift when the client#2 had the fall. He stated that the assisted living incident report was not available for review. Patient #8 Record review of Patient #8’s closed CR showed a date of admission of 10/18/2022. ISP dated 04/04/2023, was signed and dated on 10/03/2024 by OC/ PAS Supervisor and “telephone” for the Client signature portion of the form. Principal Diagnosis was Parkinson,( a disease characterized by a movement disorder with the loss of balance and coordination when moving). Authorization for 31.5 hours per week, Monday- Friday for 4.5 hours each day, to help with bathing, toileting, laundry, shaving/ oral care, dressing, routine hair/skin care, transfers, shopping, meal preparation, walking, and cleaning. Record review of document titled; “Incident Report; Jan-Mar 2023” revealed an incident on 04/28/2023 regarding Patient #8. Incident was listed as “fell-down stairs” and resolution “hospitalized”. Record review of an additional agency document titled, “Incident Report” revealed, the incident was reported to agency on 04/28/2023 at 2;40 P.M., that it alleged occurred on 04/28/2023 at 2:40 P.M. reported by PVD C. The document revealed that Client #8 had a slip/fall; continued to read in part… “the member fell; broke 3 ribs and his collar bone.” Document revealed this information was received by agency OC. Record review of agency personnel records on 07/09/2025, specifically PVD C personnel record revealed, date of hire 10/04/2022. A document titled “Policy Acknowledgement Form” …read in part... I have been given the opportunity to review all Agency administrative and clinical policies. I understand and will comply with all Agency policies… and this document was signed and dated 10/04/2022 by PVD C. On 07/10/2025 at or about 3:30 P.M. Surveyor attempted to contact PVD-C. Surveyor was unable to reach, and message was left. On 07/09/2025 at or about 11:00 A.M. an interview with OC confirmed that she received the report of the incident regarding Patient #8 and logged into the Incident Report log. OC stated that she informed the previous Admin of the incident. OC stated that she was not aware that the agency was supposed to report the fall or any other incidents like that to the designated authorities. On 07/09/2025 at or about 11:15 A.M. an interview with the agency’s DON confirmed that she was not informed about the incident because she was not employed by the agency at that time. The new owners acquired the company around 10/2024, and previous HR records are unavailable per the DON and Admin. On 07/09/2025 at or about 11:30 A.M. an interview with the Admin confirmed that she was unable to confirm any of the details of this incident as she was not employed by the agency at that time. Review of agency policy, undated, entitled “Administrative Authority and Responsibility Abuse, Neglect and Exploitation Investigation” read in part… “Policy: All the agency employees shall abide by the mandatory reporting requirements by the state statue regarding client abuse, exploitation and neglect. If this agency has cause to believe that an employee, a contractor, or a volunteer has abused, exploited, or neglected a client of the agency, the administrator or the designated person must report the information immediately to: meaning within 24 hours, to: 1. The Department of family and Protective Services and 2. The Department of Aging and Disability services.” No additional information was received.”