Every finding on record at Alma Nzeribe

A Recertification survey entrance conference was conducted with the Owner/Administrator/DON on 06/13/2024 at 11:40 AM. Census: Licensed and Certified- 0 Personal Assistance Services- 0 An exit conference was conducted with the Owner/Administrator/DON on 06/14/2024 at 2:45 PM. The preliminary findings were discussed. The agency was found to be in substantial compliance with the Medicare Conditions of Participation for Emergency Preparedness, no deficiencies were cited.

A Recertification survey entrance conference was conducted with the Owner/ Administrator/Clinical manager on 06/13/2024 at 11:40 AM. Census: Licensed and Certified- 0 Personal Assistance Services- 0 An exit conference was conducted with the Owner/ Administrator/Clinical manager on 06/14/2024 at 2:45 PM. The preliminary findings were discussed. The agency was given the opportunity to provide additional documentation within two business days, End of Business (EOB) on 06/18/2024. Instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Added note: No additional documentation was provided by the agency by the EOB 06/18/2024. ACRONYMS USED: CMS- Centers for Medicare and Medicaid Services L&CHHS- Licensed and Certified Home Health Services HCSSA- Home and Community Support Services Agencies OASIS- Outcome and Assessment Information Set iQies- Internet Quality Improvement and Evaluation System HHSC- Health and Human Services RN- Registered nurse EOB- End of business

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 records review and interview, the agency failed to electronically transmit a completed discharge OASIS (a tool used by CMS to collect certain patient information) assessment for one (Patient #1) of one patient who was discharged from the agency. Note: A home health agency must electronically send OASIS information directly to the CMS system within 30 days of completing the assessment for the patient. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. FINDINGS INCLUDE: On 06/12/2024 at 9:00 AM, the surveyor requested OASIS Provider and Quality Measure reports to be provided as scheduled through iQies. On 06/14/2024 at 2:30 PM, the surveyor reviewed the agency Activity Report in iQies from 01/01/2019 to 06/14/2024. A reassessment OASIS for Patient #1 was listed as the last OASIS transmitted by the agency on 11/07/2019. No discharge OASIS had been transmitted to OASIS for Patient #1. In an interview with the Administrator on 06/14/2024 at 2:35 PM, the surveyor asked if Patient #1 had been discharged and if so, what was the discharge date. The Administrator stated, “it’s been too long, I don’t know the discharge date, all the patients have been discharged.” The surveyor asked why the agency did not transmit a discharge OASIS for Patient #1 and who was responsible for transmitting the OASIS assessments. The Administrator stated she was responsible for everything in the agency. The Administrator stated the agency did not bill for the patient, so she didn’t think they had to transmit (the OASIS discharge assessment).

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical manager was a licensed RN. In 1 (Administrator/Clinical manager) of 2 RN license verifications completed, the Clinical manager did not have a current/active RN license to practice as a RN and was not qualified to provide oversight of patient and personnel services. Failure of the agency to ensure the Clinical manager’s RN license was current/active, potentially caused the agency to be unable to provide supervised nursing services to patients. FINDINGS INCLUDE: On 06/12/2024, at 9:00 AM, during Pre-survey review in TULIP, the surveyor noted the Clinical manager was also the owner/Administrator of the agency. On 06/13/2024 at 11:40 AM, an entrance conference was conducted with the Administrator/Clinical manager of the agency. The surveyor asked if the Administrator/ Clinical manager and the Alternate Administrator/ Alternate Clinical manager were the persons listed in TULIP. The Administrator stated, “yes.” The surveyor asked to review the personnel records for the Administrator/Clinical manager and the Alternate Administrator/Alternate Clinical manager. On 06/14/2024 at 9:50 AM, the surveyor asked to review the personnel records for the Administrator/Clinical manager and the Alternate Administrator/Alternate Clinical manager. The Administrator stated, “I don’t have the personnel files. I can’t find them. I know they’re in storage, but the people who helped me move didn’t organize anything in storage. I was ordered by the judge to vacate (the last agency location) in 3 days and that wasn’t enough time to organize anything.” On 06/14/2024 at 2:10 PM, the surveyor accessed the Texas Board of Nursing website and checked the Clinical manager’s listing for RN. The Report Summary listed the Clinical manager’s RN license as “RN, # 567232, Delinquent … Expiration date 09/30/2023.” In an interview with the Administrator/Clinical manager on 06/14/2024 at 2:15 PM, the surveyor reviewed the findings and asked if the Administrator/Clinical manager was aware her RN license was expired. The Administrator/Clinical manager stated, “yes.” The surveyor asked why the RN license was expired. The Administrator/Clinical manager stated, “I’ve been sick, I just hadn’t done it (renewed the license), we don’t have any patients.” The surveyor asked who would provide skilled nursing services to the any new patients referred to the agency. The Administrator/Clinical manager stated, “the Alternate (Clinical manager) will see the patients and if she’s not available, I’ve been in business a long time, I know a lot of nurses I can call.”