Every finding on record at All Care Professional Home Health Inc

A complaint survey was initiated on 05/08/2025 for the Complaint Intakes #1007949 and #511055. Census: Licensed and Certified- 360 Licensed Home Health- 14 Acronyms: ANE- abuse, neglect and exploitation HHSC- Health and Human Services Commission DON- Director of nurses

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to document both the existence and the resolution of a complaint for 1 (Referral #1) of 2 complaints reviewed for reported allegations of ANE. This failure could potentially place patients at risk of ANE and delay HHSC from performing an investigation. FINDINGS INCLUDE: Review of an intra-agency email (electronic mail) dated 05/02/2025, at 1:36 PM from Intake staff, Identifier G, to the DON, Quality Assurance Director, agency President, Administrator and Identifier H revealed the note: “… I got a call from (Identifier F) asking again why this patient is not receiving care. I uploaded 2 orders from them about wound care and they have not been implemented in (agency electronic medical records) nor has anything been scheduled. They had to send this patient to the hospital because he had developed maggots on his wounds due to lack of wound care. Can I get someone to call them back ad explain why this patient had not been seen or scheduled since 04/17 (2025)? They called from xxx-xxx-0714.” In an interview with the Administrator and the DON on 05/14/2025 at 3:30 PM, the surveyor reviewed the findings and asked if the agency had self-reported the complaint of alleged neglect to HHSC. The Administrator stated no report had been made for this incident. The surveyor asked why the agency did not report the allegation of neglect made by the wound care clinic. The Administrator stated reporting the incident did not occur to her at the time. Agency policy, undated, quoted in part, “ABUSE, NEGLECT AND EXPLOITATION, All agency staff, … who has cause to believe that an elderly or disabled person is in the state of abuse, neglect or exploitation shall have the legal obligation to report such …. Within 24 hours upon witnessing the act or upon receipt of the allegation, the agency must initiate an investigation of known and alleged acts of ANE by agency employees, …. The agency will investigate complaints made by … client’s health care provider, … treatment or care that the agency failed to furnish …. The agency will document receipt of the complaint and initiate a complaint investigation with [sic] 10 days after the agency’s receipt of the complaint and document all components of the investigation. ….”

An on-site investigation was conducted for IQ95989; IQ96495; IQ97935 on 05/04/2023. L & C census was 471. Acronyms/Abbreviations: L & C- Licensed and Certified Adm-Administrator Alt Adm-Alternate Administrator DON/ADON-Director of Nursing/Assistant Director of Nursing(Supervising Nurse) HHA-Home Health Agency EHR- Electronic Health Record Registered Nurse (RN) PT-Physical Therapy SOC-start of care POC- Plan of Care SN- Skilled Nursing OASIS -outcome and assessment information set N/A-Not Applicable

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview the HHA failed to integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided in three (Patient # 2, # 3, and # 6) of three patients record reviewed with delayed care and/or services, in that: 1. There was no physician’s order in the clinical record to discharge Patient #2; 2. There was no communication with the referring physician of the delay in admission for Patient #3; 3. There was no physician’s order to perform wound care (Left heel and buttocks) and there was no assessment of the Patient #6’s wound. These failures could place the patients’ health and safety at risk and cause a delay in the patients receiving needed care and services when orders are not integrated and/or coordinated with the physician. Findings included: Patient # 2: Review of the agency's complaint records revealed the following: A “Patient Complaint Form” for Patient # 2 dated 04/25/2023 with the allegation of neglect of by agency RN A. The complaint form read in part: “Wound clinic called upset about the way ‘wraps’ were put on by nurse. Upon review I saw [patient] had been discharged…[Complainant] became upset that [patient] was discharge and wanted to know who gave the order…” The complaint form was not signed by an agency staff but had the following note: “*this form must be immediately completed and forwarded to the Administrator....” Patient # 2: Review of the EHR revealed that the record contained a POC for the treatment period of 02/24/2023 to 04/24/2023 with a SOC date of 02/24/2023. The POC was signed by the Adm/DON and dated 02/24/2023. The record did not contain a POC for the current treatment period of 04/28/2023 to 06/26/2023. The record contained a POC summary with a SOC date of 04/28/2023. The record did not contain an order to discharge Patient # 2. During an interview on 05/09/2023 at 3:23 p.m. with the Adm/DON and ADON, the surveyor asked why the agency did not have an order (coordinate care and services) to discharge Patient # 2. The ADON stated that Patient # 2 told RN A that he had an amputation (removal of limb) and would be following up with the doctor on Monday. The ADON also stated that Patient # 2 told RN A to proceed with the discharge (it was the end of the treatment period). The ADON stated, that the visit should have been a recertification visit but “She [the nurse] discharged the patient. She did not call the doctor first.” Patient # 3: Review of the agency's complaint records revealed the following: A “Patient Complaint Form” for Patient # 3 dated 03/29/2023 with allegation of neglect (delayed admission) by agency. The complaint form read in part: “[Complainant] reported that [Patient # 3’s family member] reported that [Patient # 3] was not admitted yet, and [Physician, Identifier 100] wanted to know why [patient] was not admitted yet since they sent referral order 03/22/2023.” The Adm/DON signed the complaint form on 03/31/2023. Patient # 3: Record review of EHR revealed POC with a SOC date of 03/31/2023 and a treatment period of 03/31/2023 to 05/29/2023. The POC was signed by the Adm/DON and dated 03/31/2023. The record contained a referral, dated 03/23/2023, for evaluation and treatment by the HHA. The referral was from physician, (Identifier 100) and read in part: “STAT (immediately) ORDER.” The record also contained a missed visit note dated 03/23/2023 and signed by the Adm/DON that read in part: “…Per [patient family member] they are already set up with another home health agency…” The missed visit note showed that it was faxed to physician, (Identifier 200). The record did not contain any communication with the referring physician, (Identifier 100) of the missed visit or the reason for the delayed admission. During an interview with the Adm/DON and ADON on 05/09/2023 at 3:10 p.m., the surveyor asked why Patient # 3 was not admitted prior to 03/31/2023. The Adm/DON stated that the [Patient # 3’s family member] stated that he had another HHA. The surveyor also asked why the agency had not notified/coordinated care and services with physician, (Identifier 100) of the delay in admission. While reviewing the EHR, the ADON stated that the agency received the original referral from physician, (Identifier 200) on 03/22/2023; Then the agency received an “order [referral] from [physician, Identifier 100. Patient # 6: Review of EHR for Patient # 6 revealed a POC with a SOC date of 04/05/2023 and a treatment period of 04/05/2023 06/03/2023. The POC was signed by the Adm/DON and dated 04/05/2023. The POC included a diagnosis of Aftercare following joint replacement surgery. The POC also included orders for SN visits two times per week for one week, one time per week for three weeks and two as needed visits; PT visits for two times per week for three weeks starting week of 04/09/2023; and OT visits for two times per week for three weeks starting week of 04/09/2023. The POC included an SN intervention to “monitor the hip incisions for [signs and symptoms] of complication. No wound care needed at this time…” Continued review of the EHR revealed a POC Summary dated 04/05/2023. The POC Summary read in part: “…Skilled Nurse will assess patient’s wounds including measurements, treatment protocol, healing process, interventions and signs and symptoms of complications. Wound care to be performed as follows: SN to perform wound protocol…Waiting on orders…” Further review of Patient # 6’s EHR revealed pictures of wounds to buttocks. The pictures were dated 04/07/2023. The record did not include any wound care orders for the buttock wounds. Review of start of care OASIS signed by RN E and dated 04/05/2023 read in part “…[Patient] has pressure ulcer to bottom. Wife just dressed it. They have a wound care [doctor] coming tomorrow for orders…Current number of stage 1 pressure injuries…0…Stage of most problematic unhealed pressure ulcer/injury that is stageable…N/A-Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries…Wounds to bottom dressed. [Patient] declines removal of dressing at this time. [Left] heel black escher (Eschar is dead tissue that falls off (sheds) from healthy skin) open to air…Per [family member] he has some pressure ulcers to bottom area….[Patient] has a pressure spot on the left heel. It has black Escher and is open to air…” There was no picture of the heel wound in Patient # 6’s EHR. Review of SN visit notes signed by RN D and dated 04/07/2023 and 04/12/2023 did not reveal any documentation of the buttock wounds or wound care provided. The SN visit notes read in part: “…See wound care worksheet…Plans for next visit: Assessment, wound care…Interventions performed…SN to monitor the hip incisions for [signs and symptoms] of complications. No wound care needed at this time…Note/Progress Note: no [signs and symptoms] of infection…” The SN visit notes did not show or document any coordination of care with any physicians or other agency staff about Patient # 6’s wounds or wound care orders for the buttocks and to patient’s left heel). Review of PT Evaluation dated 04/10/2023 and signed by PT B read in part: “…Patient has bed sores (buttock area); RN aware per family report…” During an interview with the Adm/DON and ADON on 05/09/2023 at 3:58 p.m. The surveyor discussed the above findings and discussed why the agency failed to integrate orders from physicians, to assure coordination of services and interventions. The surveyor asked if the agency had any pictures of Patient # 6’s wounds after 04/07/2023. After reviewing the EHR the ADON replied, “No.” The ADON also stated that there were, “no pictures on 04/12/2023 (SN visit date), then he went to the hospital.” The surveyor asked if Patient # 6 was getting wound care. While reviewing the POC in the EHR the ADON stated that the POC included “no wound care needed at this time.” The surveyor asked why there was no documentation of Patient # 6’s wounds on the SN visit notes dated 04/07/2023 and 04/12/2023. The ADON stated that there were no wound care worksheets in the EHR, “She does not have it. We ask them to do it, technically it should have been done.” The surveyor asked why there was no follow-up on wound care orders as noted on the POC Summary, “waiting on orders” for the buttocks and heel wounds. The ADON replied, “That’s [the waiting on orders] probably on the incision (hip surgery incision). SN probably called the doctor and there weren’t any orders.” The surveyor also asked why there was no coordination of care with Patient # 6’s physicians to follow-up on wound care orders. The Adm/DON asked, “Are there any communication notes?” While reviewing the EHR, the ADON replied, “No communication notes.” During a telephone interview with RN D on 05/09/2023 at approximately 4:15 p.m. The surveyor asked if the nurse took pictures of the pressure wounds after the initial pictures of 04/07/2023. RN D replied, “I took pictures twice. I submit them to [the agency’s uploading program for photos].” The surveyor asked if RN D sent the pictures to the physicians involved in Patient # 6’s care. RN D replied, “I just uploaded them.” The surveyor request that the second set of pictures be sent to the surveyor (the surveyor did not receive any pictures post survey exit, on 05/09/2023). The surveyor asked if RN D follow-ed up on the wound care orders for Patient # 6’s pressure ulcers. RN D replied, “I talked to the physician several times to update on condition of the wounds and requested orders. The surveyor asked if RN D did any wound care for Patient # 6. RN D stated that she tried duoderm (an opaque dressing used in medicine to protect wounds from contamination and provide a moist wound-healing environment). RN D also stated that Patient # 6’s [family member] said that the duoderm dressing hurt Patient # 6, stuck to him and was hard to remove. The surveyor also asked if RN D had a physician’s order to use the duoderm dressing. RN D replied, “That’s what I was trying to get from the physician.” The surveyor asked why there was not documentation in Patient # 6’s record of wound assessment, wound care with duoderm, contact with physicians. RN D replied, “Okay. I thought I had put it all in there.” After reviewing the EHR RN D stated, “I really don’t know why it’s not showing up.” Review of undated agency policy titled “Care Coordination” read as follows: “This agency will promote and enforce care coordination on all patients between all service providers involved in the care of the patient, including contracted health care professionals, other agency service providers and employees of this agency. Reports of coordination will be recorded and maintained in the patient’s chart. Record of care coordination will be documented in the patient’s chart by documentation of the discipline visit notes or by the presence of a Care Coordination Note. These notes will be found in the appropriate section of the discipline completing the note.”