Links of Compassion Inc.

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on records reviewed and interviews, the agency failed to provide services as ordered by the physician for 3 of 7 discharged patients (Patients #1, 2, and 6). In that the agency failed to: 1) provide Patient #1 Nursing services as was ordered by Patient #1’s Physician. 2) Failed to provide Patient #2 Occupational Therapy and Home Health Services as ordered by Physician. 3) Failed to provide Patient #6 Occupational Therapy Services as ordered by Physician. These failures placed agency’s Patients at risk of significant functional disabilities and general poor health outcomes when the agency does not provide care according to Physicians’ orders. Findings include: Patient #1 Review of Patient #1’s electronic clinical records (ECR) revealed a home health referral order dated 10/31/2023 where Patient’s Physician requested for Nursing and Physical Therapy Services due to chronic fatigue and weakness. Continued review of Patient #1’s ECR revealed a plan of care (POC) for certification period 11/20/2023 – 01/18/2024 that showed patient’s start of care date as 11/20/2023. Review of the POC revealed Patient #1’s pertinent health information such as Patient’s Diagnoses which included: Hypertension (commonly known as high blood pressure refers to elevated blood pressure above 120/70), Chronic Fatigue (Refers to long-lasting, severe tiredness that affects daily activities that is relieved by sleep or rest), generalized muscle weakness( Refers to a reduction in muscle strength that could be due to dysfunction in the muscle group or a dysfunction of the nerve that is connected to the muscle group), and difficulty walking. Further review of the POC revealed PT listed as the only service to be provided and Nursing services was not included in the plan of care for the service period. During interview with Administrator on 04/23/2026 at 3:59pm the Administrator was asked why Nursing service was not included in this patient’s POC as ordered in Patient’s referral orders dated 10/31/2023. The Administrator did not respond to the inquiry but rather asked the Surveyor where the Surveyor saw the patient’s referral order for Nursing services. The Surveyor showed the Administrator where the Patient’s referral order was located in the Patient ECR. The Administrator reviewed the referral orders and did not ask any further questions. The Surveyor then asked the Administrator if the agency provided Nursing services to Patient #1 during that certification period. The Administrator replied, “No, we did not provide Nursing services to that patient.” Why was Nursing services not provided to the patient during the 11/20/2023 – 01/18/2024 certification period. The Administrator searching through the Patient’s clinical record said she was not sure and that was the reason she was reviewing the patient’s ECR for documentation of what happened. Patient #2 Review of Patient #2’s ECR revealed a referral order for Home Health Services dated 08/02/2023 which revealed that Physician requested for PT/OT/Home Health Aide Services. Further review of the Patient’s ECR revealed a POC for certification period from 08/14/2023 – 10/12/2023 which revealed Patient #2’s start of care date as 08/14/2023. The POC review also revealed other pertinent health information about Patient #2 such as Patient’s diagnoses which included Asthma ( a common inflammatory airway disease that results from swelling of the airway and narrowing of the airway which make breathing difficult), Pneumonia (A respiratory airway inflammation that is caused by bacterial infection and it makes the lungs tissues to harden and make air exchange in the lungs difficult), Chronic Systolic (Congestive) Heart Failure (Is a heart condition that weakens the heart muscles and make it unable to pump blood effectively to the rest of the body system). Continued review of Patient #2’s POC showed Nursing and PT listed as services to be provided to the Patient, but OT and Home Health Aide services were not included in the plan of care. Further review of Patient #2’s ECR did not show that agency provided Home Health Aides and OT services to the Patient during the certification period. During interview with the Administrator on 04/23/2026 at 3:43pm, the Administrator/Alternate Supervising Nurse was asked why OT and Home Health services were not included in the patient’s POC and if the Agency provided these services to the Patient during the service period. The Administrator/ Alternate Supervising Nurse searched through Patient # 2’s ECR but did not respond to the inquiry. After repeated inquiries the Administrator stated that she saw in the record that Patient #2 had only one visit and every other visit was missed but she did not see any communication notes in the Patient’s records that showed the reason for the missed visits or why the OT and Home Health Aide services were not included in the Patient’s Plan of Care. The Administrator further stated that she was not sure that Agency provided OT and Home Health Aide Services to the Patient. During continued interview with the Administrator/Alternate Supervising Nurse, the Surveyor asked who was responsible for ensuring that Agency’s patients were seen and services were provided as ordered according to the POC. The Administrator stated that the Supervising Nurse was responsible for ensuring that Patients were visited and services provided as scheduled. The Administrator was also asked who was responsible for creating agency’s Patients’ plan of Care and ensuring that Physicians’ orders were correctly transcribed to the POCs. The Administrator stated that the Admitting Nurses were responsible for creating the Patients’ plan of care based on their initial Assessment of the Patients’ needs and the Physicians’ orders. Surveyor then requested to speak with the Nurse (RN A) that conducted the initial comprehensive assessment for Patient 2. The Administrator/Alternate Supervising Nurse picked up her phone and acted as if she was dialing the RN A’s phone number and then kept the phone down. After some time had passed Surveyor requested for the Administrator to call RN A. The Administrator stated that she texted RN A but did not get any response to her text message. Surveyor requested that Administrator call the RN A. The Administrator called the RN A’s phone and left a voicemail requesting a call back. RN A never called back. On continued interview with Administrator/Alternate Supervising Nurse on 04/23/2026, Surveyor requested to speak with Agency’s Supervising Nurse/Alternate Administrator. The Administrator stated that the agency’s Supervising Nurse/Alternate Administrator was on vacation and could not be reached. Surveyor also requested to speak with the Physical Therapist who was assigned to provide PT services to Patient 2. The Administrator/Supervising Nurse tried to contact the Physical Therapist by phone there was no response to the call, the Administrator left a voicemail requesting a call back. The Physical Therapist did not return the call. Patient #6 Review of Patient #6’s ECR revealed a home health order dated 04/14/2023 that showed that Patient #6’s Physician ordered PT/OT services for the patient. Review of Patient #6’s plan of Care only had PT listed as the service ordered for the patient and OT service was not included in the POC. Review of Patient #6’s POC for certification period from 04/05/2023 – 06/03/2023 showed the patient’s start of care date as 04/05/2023. The POC review also revealed other pertinent health information about Patients #6 such as patient’s diagnoses which included: Stage 2 Pressure Ulcer (Wound that is caused as a result of applying continuous pressure to a body part) on the left buttocks, Hypertension (commonly known as high blood pressure refers to elevated blood pressure above 120/70), Paraplegia (Numbness or paralysis of a half part of a person’s body usually an arm and leg of the same side of the body) and generalized weakness (a reduction in muscle strength that could be due to dysfunction in the muscle group or a dysfunction of the nerve that is connected to the muscle group). During interview with the Administrator on 04/23/2026 3:59p the Administrator/Alternate Supervising Nurse was asked why OT service was not included in the Patient’s plan of care as part of the services that was ordered by Patient’s physician. The Administrator did not respond to the inquiry. The Administrator was asked if the patient received OT Services during that service period. Administrator/Alternate Supervisor Nurse replied, “No.” In a continued interview the Surveyor asked why OT was not provided as was ordered by Patient’s Physician. The Administrator did not respond to the inquiry. Surveyor then asked who was responsible for making sure that the physician’s orders for services were transcribed into the POC correctly and that the patient received services as order. The Administrator stated “that would be the Alternate Administrator/Supervising Nurse, but she was unavailable at the moment. She is on vacation. What is your agency’s process for developing patients’ POC and what is your agency’s policy on creating or developing plans of care for your patients because looking at this patient’s POC it showed that you signed off on it. Did you develop the POC for this patient. Administrator Stated that she did not create this POC, but she did sign it. The Administrator stated that agency’s policy was to review the physician’s orders and assess the patient and then create a plan of care that best met the needs of the patient. The Administrator also stated that she did not create agency’s patients’ plans of care but the Nurses that conduct the initial assessment during admission and the reassessments of agency’s patients create the patients’ POCs. Surveyor then pointed out to the Administrator/Alternate Supervising Nurse that she signed off on all plans that were reviewed. So, what’s your agency’s process for signing off on patients’ plans of care. The Administrator stated that she was supposed to review the patients’ referral orders to ensure that all the requested orders were included in the POCs before signing off the POCs and she stated that she did not follow that process. Review of agency’s Administrative policy titled, “Start of Care (SOC) Referral, Admission, and Initial Assessment” last reviewed on 01/02/2026 reads in part, “…To establish a standardized process for accepting referrals, admitting clients, and initiating care at Links of Compassion Inc. This policy ensures that every client admitted to the agency receives a timely, accurate, and complete initial assessment, that appropriate orders are obtained before care is delivered, and that each team member understands their specific responsibility in the Start of Care (SOC) process in compliance with 26 TAC Chapter 558 and 42 CFR Part 484…” The Policy further states that patients’ plans of care are to be developed based on the physicians’ orders and the initial comprehensive assessments of the patients.”