Diamond Heart Healthcare Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to comply with all applicable State emergency preparedness requirements, in that: the agency failed to maintain an emergency preparedness plan that was reviewed (to evaluate the plan’s effectiveness) and updated at least annually per state regulatory requirements for three (2022, 2023, and 2024) of three years reviewed. The failure placed the agency’s patients at risk of harm and at risk of their safety being compromised if the EP plan was not effective and needed updating. Findings include: Review of the undated emergency preparedness and response plan binder on 03/31/2025 did not reveal any completed reviews of the agency’s EP plan for the years 2022, 2023 and, 2024. Further review of the binder revealed that the last review (emergency prepared plan evaluation) was dated 01/18/2021. During an interview with the Admin/DON on 03/26/2025 at approximately 4:30 p.m. the surveyor asked if the agency had provided all agency requested records for the agency’s EP program. The Admin/DON nodded his head, yes, that the agency had provided the requested records. During an interview with the Admin/DON and Alt. Admin/ADON on 04/01/2025 at 1:46 p.m., the surveyor asked who the agency’s disaster coordinator and alternate coordinator was. The Admin self-identified as the coordinator and the Alt Admin self-identified as the alternate coordinator. The surveyor asked who was responsible for the agency’s emergency preparedness program. The Alt Admin stated that the Admin was responsible for the program. The surveyor asked what the agency’s processes were for reviewing the agency’s EP plan/program. The Admin/DON replied, “We follow our policies.” He stated that the agency had a call tree, the agency called the agency’s staff, and patients if there was a storm. He stated that when the agency received an alert from HHSC the agency tried to follow “our policies.” The surveyor reviewed the findings and asked why the agency had not completed at least annual reviews of the agency’s EP plan for 2022, 2023, and 2024. The Admin/DON replied, “Could be an oversight.” The surveyor also asked how not completing the annual reviews of the agency’s EP plan could adversely affect the agency’s patients. The Admin/DON replied, “It could lead to fatal outcomes. If they don’t have updated information, the safety of the staff and the patients could be compromised.” Review of agency policies titled “Emergency Preparedness and Response Plan EC. 40 [and]-Addendum EC.40 TX” last reviewed 05/01/24 read in part: “ ...PURPOSE I. To ensure the Agency complies with all applicable Federal, State and local emergency preparedness requirements. II. To ensure the Agency develops, establishes, maintains, and implements emergency policies and procedures, based on the risk assessment, emergency plan, communication plan, and testing and training program…Policy II. The Agency will have a written Emergency Preparedness and Response Plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or the ability to provide those services. The plan will…E. Be reviewed and updated, including related polices, at least every two years… [continued review of Addendum EC.40 TX revealed the following] Policy [:] 1…in reference to the review and update frequency requirement of every two years: A. The Agency will complete an internal review of the emergency Preparedness and Response Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and update the plan as needed...””

“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 regarding each beneficiary (patient), within 30 days of completing the OASIS assessment, in that; For report period 03/25/2024 to 03/25/2025 (23.19 percent) of OASIS assessments had submission dates that were more than 30 days after the M0090 date (date OASIS assessment completed). The failure prevented the patients’ data from being available to CMS for timely analysis to identify agency performance levels in the provision of patient care and treatment. Findings include: Review of iQIES (Internet Quality Improvement & Evaluation System) on 03/25/2025 revealed the Agency’s OASIS error summary report for the report period 03/25/2024 to 03/25/2025. Review of the report revealed the following: error description “Record Submitted Late: The submission date was more than 30 days after the M0090 date on this new record; [The number] of assessments processed 138; [The number] of assessments with [a late submission] error 32; [and the percentage] of assessment with [a late] error [23.19 percent].” During an interview with the Admin/DON on 04/01/2025 at 1:50 p.m., the surveyor asked who at the agency was responsible for submitting the agency’s OASIS assessments. The Admin/DON stated that he was responsible. The surveyor asked what the agency’s process was for submitting the agency’s OASIS assessments. The Admin stated that when the OASIS assessments were transmitted through IQIES (an internet-based system used by CMS to manage provider and patient information). The surveyor reviewed the findings and asked why the OASIS assessments were not submitted timely (within 30 days of the completion date). The Admin/DON stated that the managed care organizations wanted the agency to fax the assessments directly to them. He stated that the agency contacted CMS and was instructed that the OASIS must be transmitted to CMS. The Surveyor asked if the Admin was aware of the percentage of the late submissions. The Admin/DON replied, “I didn’t know it was up to 20 percent.” Review of agency policy titled, “Timelines” last reviewed 10/25/24 read in part: “…Policy The Agency will ensure timely provision of services to meet the patient’s needs in compliance with all federal and state laws and regulations. Procedure… C. A registered nurse, physical therapist, or speech therapist will complete the Initial Comprehensive Assessment no later than five calendar days after the start of care (SOC) for all patients/clients in a licensed and certified agency… E. Recertifications/comprehensive reassessments will be completed no earlier than five days prior to end of the episode and no later than the last day of the episode (the 56th through the 60th day… II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard…from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date…” M0090- date is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific responses was completed. OASIS -outcome and assessment information set (is a group of standard data elements home health agencies integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s), for three (2022, 2023, and 2024) of three years reviewed, that reflected the scope, complexity and past performance of the agency’s services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to health and safety concerns. Findings include: Review of agency’s undated QAPI binder did not reveal any documentation that indicated the agency had: any quality improvement projects undertaken, (in development, ongoing, or completed) the reason for conducting the projects, and the measurable progress achieved on the projects for each calendar year of 2022, 2023, and 2024. Continued review of the binder did not reveal any PIPS. During an interview on 04/01/2024 at 4:12 p.m. with the Admin/DON and Alt Admin/ADON, the surveyor asked who was responsible for the agency’s QAPI program. The Alt Admin/ADON stated that, “The two of us.” was responsible for the program. The surveyor asked what the agency’s processes were for its performance improvement projects. The Admin/DON stated that the agency followed its policies. The surveyor asked why the agency had not conducted and documented project improvement projects. The Admin/DON stated, “We did not do it the way we were supposed to (according to agency policies). The surveyor asked why the agency was not following its policies and regulations. The Alt Admin/ADON replied, “We are overwhelmed with all the work.” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON stated, “The quality of care will decline [for the patients].” Review of agency policy titled; “Quality Assessment Performance Improvement Program” last reviewed 05/01/24 revealed the following: “…E. Performance Improvement Projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. ...””

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure that the comprehensive assessment was updated and revised not less frequently than the last five days of every 60 days beginning with the start of care, in that: for four (Patients # 1, 3, 4, and 5) of five active patient records reviewed the comprehensive assessment including the OASIS was not updated and revised during the last five days of every 60 days beginning with the SOC date. The failure caused the patients’ to not have their current health status assessed and updated. Findings Include: Active Clinical Record # 1: Record review of the clinical records for Patient # 1 revealed an updated comprehensive assessment/recertification OASIS for the certification period of 01/25/2025 to 03/25/2025. Review of the assessment revealed the following: The assessment included a start of care date of 11/26/2024; was completed and electronically signed by the Alt Admin/ADON on 01/21/2025. Continued review (on 03/27/2025) of Patient # 1’s electronic clinical record did not reveal any updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/26/2025. Further review of Patient # 1’s records did not show that a comprehensive assessment/OASIS had been updated and revised during the last five days of every 60 days (for the current certification period beginning on 03/26/2025) which was due for completion by 03/25/2025. Active Clinical Record # 3: Record review of the clinical records for Patient # 3 revealed an updated comprehensive assessment/recertification OASIS for the certification period of 01/21/2025 to 03/21/2025. Review of the assessment revealed the following: The assessment included a start of care date of 11/22/2024; was completed and electronically signed by the Alt Admin/ADON on 01/17/2025. Continued review (on 03/27/2025) of Patient # 3’s electronic clinical record did not reveal any updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/22/2025. Further review of Patient # 3’s records did not show that a comprehensive assessment/OASIS had been updated and revised during the last five days of every 60 days (for the current certification period beginning on 03/22/2025) which was due for completion by 03/21/2025. Active Clinical Record # 4: Record review of the clinical records for Patient # 4 revealed a comprehensive assessment/start of care OASIS for the certification period of 01/10/2025 to 03/10/2025. Review of the assessment revealed the following: The assessment included a start of care date of 01/10/2025; was completed and electronically signed by the Alt Admin/ADON on 01/10/2025. Continued review (on 03/27/2025) of Patient # 4’s electronic clinical record did not reveal any updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/11/2025. Further review of Patient # 4’s records did not show that a comprehensive assessment/OASIS had been updated and revised during the last five days of every 60 days (for the current certification period beginning on 03/11/2025) which was due for completion by 03/10/2025. Active Clinical Record # 5: Record review of the clinical records for Patient # 5 revealed a comprehensive assessment/start of care OASIS for the certification period of 01/17/2025 to 03/17/2025. Review of the assessment revealed the following: The assessment included a start of care date of 01/17/2025; was completed and electronically signed by the Admin/DON on 01/17/2025. Continued review (on 03/27/2025) of Patient # 5’s electronic clinical record did not reveal any updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/18/2025. Further review of Patient # 5’s records did not show that a comprehensive assessment/OASIS had been updated and revised during the last five days of every 60 days (for the current certification period beginning on 03/18/2025) which was due for completion by 03/17/2025. An interview was conducted with the Admin/DON and Alt Admin/ADON on 04//01/2025 at 3:10 p.m., the surveyor reviewed the findings and asked who at the agency was responsible for completing the assessments. The Alt Admin/ADON stated that she was responsible. The surveyor asked if the patients had been discharged. The Admin/DON replied, “No we have not discharged them.” The Surveyor asked why the assessments had not been completed on time. The Alt Admin/ADON stated that she was just running late on it. The surveyor asked how the failure could adversely impact the patients. The Admin/DON stated that there might be some medication changes or change in patient care that might be missed. The Alt Admin/ADON stated that the failure might cause a delay in service provision. Record review of agency policy titled, “Patient/Client Reassessment/Recertification…” last reviewed 05/01/24 read in part: “...II. The recertification/...comprehensive Assessment… will be updated and revised…not less frequently than…during the last five...days of every 60… days beginning with the Start of Care date...” Review of agency policy titled, “Timelines” last reviewed 10/25/24 read in part: “…Policy The Agency will ensure timely provision of services to meet the patient’s needs in compliance with all federal and state laws and regulations. Procedure… C. A registered nurse, physical therapist, or speech therapist will complete the Initial Comprehensive Assessment no later than five calendar days after the start of care (SOC) for all patients/clients in a licensed and certified agency… E. Recertifications/comprehensive reassessments will be completed no earlier than five days prior to end of the episode and no later than the last day of the episode (the 56th through the 60th day…)””

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview the agency failed to have a revised plan of care that reflected current information from the patient’s updated comprehensive assessment, in that: for four (Patients, 1, 3, 4, and 5) of five active patient records reviewed the patients did not have a current plan of care or updated comprehensive assessment. The failure placed the patients’ health at risk of decline due to not having their current health care needs assessed and included in an individualized plan of care. Findings include: Active Clinical Record # 1: Record review of the clinical records for Patient # 1 revealed a plan of care and an updated comprehensive assessment/recertification OASIS for the certification period of 01/25/2025 to 03/25/2025. Review of the plan of care revealed the following: a start of care date of 11/26/2024; was completed and electronically signed by the Alt Admin/ADON on 01/21/2025. Continued review (on 03/27/2025) of Patient # 1’s electronic clinical record did not reveal any revised plan of care or updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/26/2025. Further review of Patient # 1’s records did not show that a revised plan of care or comprehensive assessment/OASIS had been updated and revised for the current certification period beginning on 03/26/2025, which was due for completion by 03/25/2025. Active Clinical Record # 3: Record review of the clinical records for Patient # 3 revealed a plan of care and updated comprehensive assessment/recertification OASIS for the certification period of 01/21/2025 to 03/21/2025. Review of the plan of care revealed the following: a start of care date of 11/22/2024; was completed and electronically signed by the Alt Admin/ADON on 01/17/2025. Continued review (on 03/27/2025) of Patient # 3’s electronic clinical record did not reveal any revised plan of care or updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/22/2025. Further review of Patient # 3’s records did not show that a plan of care or comprehensive assessment/OASIS had been updated and revised for the current certification period beginning on 03/22/2025 which was due for completion by 03/21/2025. Active Clinical Record # 4: Record review of the clinical records for Patient # 4 revealed a plan of care and comprehensive assessment/start of care OASIS for the certification period of 01/10/2025 to 03/10/2025. Review of the plan of care revealed the following: a start of care date of 01/10/2025; was completed and electronically signed by the Alt Admin/ADON on 01/10/2025. Continued review (on 03/27/2025) of Patient # 4’s electronic clinical record did not reveal any revised plan of care or updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/11/22025. Further review of Patient # 4’s records did not show that a revised plan of care or comprehensive assessment/OASIS had been updated and revised for the current certification period beginning on 03/11/2025 which was due for completion by 03/10/2025. Active Clinical Record # 5: Record review of the clinical records for Patient # 5 revealed a plan of care and comprehensive assessment/start of care OASIS for the certification period of 01/17/2025 to 03/17/2025. Review of the plan of care revealed the following: a start of care date of 01/17/2025; was completed and electronically signed by the Admin/DON on 01/17/2025. Continued review (on 03/27/2025) of Patient # 5’s electronic clinical record did not reveal any revised plan of care or updated comprehensive assessment/recertification OASIS for the current certification period that was due on 03/18/2025. Further review of Patient # 5’s records did not show that a revised plan of care or comprehensive assessment/OASIS had been updated and revised for the current certification period beginning on 03/18/2025 which was due for completion by 03/17/2025. An interview was conducted with the Admin/DON and Alt Admin/ADON on 04//01/2025 at 3:10 p.m., the surveyor reviewed the findings and asked who at the agency was responsible for completing the assessments and plan of cares. The Alt Admin/ADON stated that she was responsible. The surveyor asked if the patients had been discharged. The Admin/DON replied, “No we have not discharged them.” The Surveyor asked why the assessments and plan of cares had not been completed. The Alt Admin/ADON stated that she was just running late on it. The surveyor asked how the failure could adversely impact the patients. The Admin/DON stated that there might be some medication changes or change in patient care that might be missed. The Alt Admin/ADON stated that the failure might cause a delay in service provision. Review of agency policy titled, Plan of Care” last reviewed 05/02/24 read in part: “…IV. All patient/client care orders, including verbal orders, must be recorded in the Plan of Care. A. The POC may include orders for treatment or services received from physicians other than the responsible physician… VI. The individualized Plan of Care must be reviewed and revised by the physician and/or non-physician practitioner who is responsible for the home health Plan of Care and the Agency as frequently as the patient’s/client’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date…””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review, observations, and interviews the agency failed to provide the patient a written visit schedule with frequency that was consistent with the patient’s most current plan of care for three (Patients # 1, 2, and 3) of three patients who received a home visit and whose home admission folder was reviewed. The failure placed the patient’s health and safety at risk if the patient and caregiver did not understand what services to expect from the HHA, the purpose of each service and when to expect the services. Findings included: Patient # 1 Review of the clinical records for Patient # 1 revealed a POC for the certification period of 01/25/2025 to 03/25/2025. Review of the plan of care revealed the following: a start of care date of 11/26/2024; was completed and electronically signed by the Alt Admin/ADON on 01/21/2025. Continued review of the POC revealed a primary diagnosis of Type 2 diabetes (is a condition where the body does not produce enough or does not utilize insulin effectively in the regulation of blood sugar levels). The POC contained an order for skilled nursing visits for one time per week for nine weeks and one or two as needed visits. During a home visit with Patient # 1 conducted on 03/28/2025 at 3:30 p.m., the surveyor observed and reviewed the agency admission folder provided to the patient. The review revealed it did not include a written visit schedule that included frequency of visits by HHA personnel. Patient # 1 stated that no papers had been removed from the admission folder. Patient # 2 Review of the clinical records for Patient # 2 revealed a POC for the certification period of 02/27/2025 to 04/27/2025. Review of the plan of care revealed the following: a start of care date of 02/27/2025; was completed and electronically signed by the Alt Admin/ADON on 02/27/2025. Continued review of the POC revealed a primary diagnosis of Hypertension (high blood pressure). The POC contained an order for skilled nursing visits for one time per week for eight weeks and one or two as needed visits. During a home visit with Patient # 2 conducted on 03/28/2025 at 10:00 a.m., the surveyor observed and reviewed the agency admission folder provided to the patient. The review revealed it did not include a written visit schedule that included frequency of visits by HHA personnel. Patient # 2 stated that no papers had been removed from the admission folder. Patient # 3 Review of the clinical records for Patient # 3 revealed a POC for the certification period of 01/21/2025 to 03/21/2025. Review of the plan of care revealed the following: a start of care date of 11/22/2024; was completed and electronically signed by the Alt Admin/ADON on 01/17/2025. Continued review of the POC revealed a primary diagnosis of Hypertension (high blood pressure). The POC contained an order for skilled nursing visits for one time per week for nine weeks and one or two as needed visits. During a home visit with Patient # 3 conducted on 03/28/2025 at 11:25 a.m., the surveyor observed and reviewed the agency admission folder provided to the patient. The review revealed it did not include a written visit schedule that included frequency of visits by HHA personnel. Patient # 3’s representative stated that no papers had been removed from the admission folder. During an interview on 04/01/2025 1:18 p.m., the surveyor reviewed the findings with the Admin/DON and Alt Admin/ADON and asked who was responsible for providing the written information to the patients. The Admin/DON stated that the person who conducted the admission visit was responsible. The surveyor asked why Patients # 1, 2, and 3’s home written records did not include a written visit schedule that included frequency of visits in accordance with regulatory requirements. The Alt Admin/ADON stated that she did not know the visit schedules were not there. (The Admin/DON and Alt Admin/ADON were the admission nurses for Patients # 1, 2, and 3). The surveyor asked how the failure could adversely affect the patients. The Admin/DON stated that the patients would not know what to expect. Review of agency policy titled, “Implementing Care and Treatment” last reviewed 05/02/24, read in part: “…VI. Written information to the patient/client. A. The Agency must provide the patient/client, and caregiver, with a copy of written instructions outlining: 1. The visit schedule, including frequency of visits by Agency personnel and personnel acting on behalf of the Agency…””