Every finding on record at Alpha Mk Healthcare Inc

A recertification survey was conducted on 06/27/2022 at 11:30 AM with the Alternate Administrator. The census was 21. 0 Licensed and Certified 21 Personal Assistance Services An exit conference was conducted on 07/07/2022 at 2:30 PM with the Alternate Administrator. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

A recertification survey was conducted on 06/27/2022 at 11:30 AM with the Alternate Administrator. The census was 21. 0 Licensed and Certified 21 Personal Assistance Services An exit conference was conducted on 07/07/2022 at 2:30 PM with the Alternate Administrator. Abbreviations: PRN=as needed DON=Director of Nursing PT= Physical Therapist OT = Occupational Therapist LVN = Licensed Vocational Nurse TULIP = Texas Uniform Licensure Information Portal COVID-19 = Novel Coronavirus SARS – CoV2 OASIS = Outcome and Assessment Information Set RN = Registered Nurse POC = Plan of Care PAS = Personal Assistance Services QAPI = Quality Assurance Performance Improvement L&C = Licensed and Certified

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure 5 (Patient 1,4,5,6, and 7) of 7 patient records reviewed received the home health services that were written in an individualized plan of care which was established, periodically reviewed, and signed by a physician. In two (Patient 4 & 5) of two records reviewed who received nursing and therapy services, the POC failed to include orders for therapy services. The outcome was the patients received nursing and physical therapy services without signed orders for care from a physician subjecting the patients to poor quality care and increased potential for adverse health outcomes such as complications from high blood pressures, high blood sugar, high levels of pain, a lack of progress with Physical Therapy goals, a lack of Physical and Occupational Therapy services, and rehospitalization. Review of the clinical record for Patient 1 revealed an unsigned POC for nursing care provided 11/01/2019 to 12/30/2019. The POC ordered weekly nursing visits for Patient 1 for diagnoses of Diabetes Mellitus, Hypertensive Heart Disease, and Rheumatoid arthritis. The POC ordered a blood sugar parameter of less than 60 and greater than 200. Nursing visits were documented on 11/08/2019, 11/12/2019, 11/21/2019, 12/12/2019, 12/19/2019, and 12/27/2019. The patient had high blood sugar readings of 204 on 12/12/2019 and 12/19/2019. Review of the clinical record for Patient 4 revealed an unsigned POC for nursing and physical therapy care provided 04/19/2021 to 06/17/2021. The POC ordered weekly nursing visits and physical therapy to evaluate and treat for Patient 4 for diagnoses of Diabetes Mellitus Type 2 with Neuropathy, Abnormalities of Gait and Mobility, Chronic Pain, Hypertension, Insomnia, Personal History of Nicotine Dependence, Need for Assistance with Personal Care, and Need for Assistance at Home and no other Household member able to Render Care. The POC ordered a systolic blood pressure parameter of 90 to 160 and a diastolic blood pressure parameter of 90 to 60. A pain level parameter of greater than 5 was also ordered on the POC. Nursing visits and adverse health outcomes for Patient 4 were documented as follows. On 05/01/2021 the Client reported a pain level of 8. On 05/08/2021 the pain level was 8 and the blood pressure was 162/113, and no blood sugar results were documented. On 05/15/2021 and 05/22/2021, the pain level was 6 and no blood sugar results were documented. On 05/29/2021, the pain level was 8 and no blood sugar results were documented. On 06/05/2021, the pain level was 7 and no blood sugar results were documented. A physical therapy evaluation dated 05/07/2021with ordered care once a week for one week, twice a week for 3 weeks, and one a week for one week for the certification period of 04/19/2021 to 06/17/2021. The evaluation was unsigned, and the record review revealed no signed order for therapy services. The Physical Therapist documented the pain level was 6 on 05/14/2021. Physical therapy visits were also documented on 05/18/2021, 05/21/2021, 05/25/2021, 05/29/2021, 06/02/2021 and a Physical Therapy discharge visit on 06/11/2021 documented lack of progress and goals partially met as the reason for discharge. The PT discharge summary and order were not signed by the physician. Review of the clinical record for Client 5 revealed an unsigned POC for nursing care provided 12/04/2020 to 02/01/2021. The POC ordered weekly nursing care for diagnoses of Heart Disease, Osteoarthritis, Chronic Obstructive Pulmonary Disease, Abnormalities of Gait and Mobility, and Hypertension. The POC contained goals for Physical Therapy Services, but no orders for Physical or Occupational therapy services. The POC ordered no specific parameters for blood pressure for the client with Hypertension, but did order the Skilled nurse to monitor and report to physician any significant findings. (High blood pressures in older adults are numbers above 130 / 80 according to the National Institute on Aging.) The POC ordered the nurse to assess the patient for pain every visit but failed to order a parameter for pain to be reported to the physician. According to the National Institute of Health pain scales measure a person’s severity of pain with zero meaning no pain to 10 meaning “the worst possible pain.” The record contained a document labeled face to face signed by the physician who ordered nursing, physical therapy, and occupational therapy services for the client for cardiac needs, skilled monitoring for change / decline in status, assistance with medication management, teaching and training of disease process and symptom management, PT/OT evaluations for gait training, strengthening, instruction in use of assistive devices, and home safety adaptation to address unsteady gait, poor ambulation and prone to falls, compromised mental status, and severe dyspnea on exertion. Nursing visits and adverse health outcomes were documented as follows. On 12/10/2020 the patient reported a pain level of 7. On 12/16/2020 the patient reported a pain level of 8. On 12/23/2020 the patient reported a pain level of 8 and a high blood pressure of 168/74. On 12/28/2020 the patient reported a pain level of 8. Review of the clinical record for Client 6 revealed an unsigned POC for nursing care provided 10/13/2020 to 12/11/2020. The POC ordered weekly nursing care for diagnoses of Diabetes Mellitus Type 2 with Neuropathy, Heart Disease, Osteoarthritis and Hypertension. The POC ordered a systolic blood pressure parameter of 90 to 160 and a diastolic blood pressure parameter of 60 to 90. A pain level parameter of greater than 5 was also ordered on the POC. Nursing visits and adverse health outcomes were documented as follows: On 10/23/2020, the patient reported a pain level of 6. On 10/30/2020, the patient’s pain level was 8. On 11/07/2020, the patient’s pain level was 6. On 11/13/2020, the patient’s pain level was 8. On 11/18/2020, the patient’s pain level was 8. On 11/28/2022, the patient’s pain level was 7 and the patient reported frequent falls. On 12/04/2020, the patient’s blood pressure was 192/114, the pain level was 7 and the nurse note documented “frequent falls.” The record contained an undated discharge summary that revealed the patient was transferred to the hospital and discharged from agency services. Review of the clinical record for Client 7 revealed an unsigned POC for nursing care provided 05/08/2021 to 07/06/2021. The POC ordered weekly nursing care for diagnoses of Bilateral Osteoarthritis of the Knee, Osteoporosis, Low Back Pain, Hypertensive Heart Disease, and Calculus of Kidney. The POC ordered the nurse to assess the patient for pain every visit but failed to order a parameter for pain to be reported to the physician. The POC listed a pain goal of 1/10 by the end of the episode. According to the National Institute of Health pain scales measure a person’s severity of pain with zero meaning no pain to 10 meaning “the worst possible pain.” Nursing visits and adverse health outcomes were documented as follows. On 05/14/2021, 05/19/2021, 05/26/2021, 06/02/2021, 06/09/2021, 06/16/2021 the nurse documented the patient’s pain level was 7. On 06/21/2021the nurse documented the patient’s pain level was 8. On 07/06/2021 the nurse documented the patient’s pain was from 5 to 10 and the patient’s family requested discharge from the agency. An interview was conducted with RN A on 07/01/2022 at 2:24 PM. The RN stated she was not currently and had never been the DON for the agency. The RN stated she had completed OASIS assessments and some nursing visits. The RN stated she did not know why the Plans of care were not signed, why the POCs did not contain therapy orders for Patients 4 and 5. The RN stated she did not review the POCs, did not supervise the LVNs, and only did the OASIS assessments and a few visits for the agency. The RN suggested asking the Alternate Administrator who ran the agency. An interview was conducted with RN B on 07/07/2021 at 7:54 AM. The RN stated she had not been the DON for the agency, and “the agency just put your name on the paperwork because they don’t want to pay for a DON.” The RN stated she did OASIS assessments and some visits for the agency. The RN stated she did not know why the POC’s did not have doctor’s signatures. An interview was conducted with the Alternate Administrator on 07/07/2022 at 1:20 PM. The surveyor reviewed the lack of physician signatures on PT evaluations /orders for the patients. The surveyor asked about the lack of physician signatures. The Alternate Administrator stated: “The doctors won’t sign them. We follow up. The PT collected their money, and we did not.” The surveyor asked about the lack of physician signatures on the Plans of Care. The Alternate Administrator stated: “All these doctors didn’t send it (the signed plans of care).” The surveyor asked about the outcome of no signed orders for the patients. The Alternate Administrator stated: “Most moved to another agency, because really they (Medicare) don’t pay us.” We send the orders to the doctors and follow[RG(2] up and follow up. The surveyor asked about the effect on the patients of the lack of signed orders, how that might cause issues in patient care. The Alternate Administrator stated: “Because of my absence, I was sick and, in the hospital, and still have to have labs every 2 weeks, some things didn’t get done.” Agency policy titled “Plan of Care/Service” with no date read in part: “Policy- It shall be the policy of this Alpha-MK Health care Inc. to develop and implement an individualized Plan of Care of Plan of Service to address patient/client’s goals and the specific care of (sic) services to be provided for each patient/client admitted for care/service…The Plan of Care/Service is reviewed and revised whenever necessary to accommodate changes in patient/client needs, health status, environment and/or changes in services and at least: a. Every sixty (60) days … Directed/signed by the attending physician at least every sixty (60) days… Scope Applicable to all Alpha-MK Healthcare Inc. patients/clients admitted for service. Responsibility Director of Nursing. Agency policy titled “Physician Orders” with no date ready in part: “Policy – Physician orders will be obtained for all care or services to be provided to Alpha-MK Healthcare Inc. patient/client …. Signed physician orders will be in the clinical record within 60 days of initiation of care or new orders, unless otherwise specified by applicable state law and regulation…. Responsibility- Director of Nursing.”

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 Performance improvement projects for three of three years of the survey review 2019, 2020, and 2021. The outcome was the agency was not focused on determining and completing the required projects. This could affect the care for future clients for the agency. The surveyor requested the QAPI documents for 2019, 2020, 2021, and 2022 during the entrance conference on 06/27/2022 at 11:30 AM. 0n 06/27/22 at 3:15 PM, the surveyor reviewed the QAPI black three ring binder labeled Alpha – MK Healthcare, Inc. Quality Assurance Performance Improvement Manual provided by the Office Manager. Review of the QAPI plan, QAPI committee meeting minutes, agency annual evaluation, and other documents in the QAPI binder provided revealed no evidence of performance improvement projects for 2019, 2020 and 2021. Review of the agency policy and procedures manual provided revealed no policy for performing improvement projects. An interview was conducted with the Alternate Administrator on 06/30/2022 at 4:12 PM. The surveyor reviewed the QAPI record findings and asked about the Performance Improvement Projects. The Alternate Administrator stated RN A did the QA for the agency. The surveyor asked why there were no performance improvement projects in the QAPI committee meeting minutes for 2019, 2020, and 2021. The Alternate Administrator stated it was because “the previous surveyor did not tell us about that.” The surveyor asked if the agency had discussed, planned, and conducted any performance improvement projects for the last three years. The Alternate Administrator stated they didn’t have any current patients, so they were not doing any. The surveyor asked about the outcome of the agency having no projects planned or conducted for the three years. The Alternate Administrator stated the agency had a hard time since Medicare stopped paying the agency and they had been focusing on paying the taxes owed and the cost report, and the Alternate Administrator stated his health had not been good the previous year and he had been in and out of the hospital and was better now, but some things had not been done. The surveyor asked about the effect on the patients of the agency not conducting the required performance improvement activities. The Administrator stated that they didn’t have any active patients since March or April 2021. The Administrator stated the agency would be accepting patients in the future and were receiving referrals but had not accepted any new clients for about a year while they worked to resolve the other issues.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on observation, record review and interview the Governing body failed to assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans and its quality assessment and performance improvement program for 3 (2019, 2020, 2021, and currently through July 2022) of 3 years reviewed during the survey. The outcomes were the agency had no effective mechanism to monitor, evaluate and improve the care and services to the agency clients, a lack of oversight and appropriate staff to monitor the quality of services and ensure the functions of the agency, and the agency had conducted no performance improvement projects for 3 years. This could affect the care for current and future clients for the agency. A. The agency failed to ensure the QAPI Committee membership consisted of the supervising nurse, and an individual representing the scope of therapy services provided by the agency for 2020, 2021, and 2022. B. The agency failed to maintain a QAPI Program 2019, 2020, and 2021 to include: a system that measures significant outcomes for optimal care for the personal assistance program, an analysis of a representative sample of services furnished to clients contained in both active and closed records, and a determination that services have been performed as outlined in the individualized service plan or plan of care. C. The agency failed to conduct Performance improvement projects for 2019, 2020, and 2021. On 06/27/2022 at 11:30 AM, the surveyor requested the QAPI documents for 2019, 2020, 2021, and 2022 during the entrance conference. The surveyor confirmed the agency services included licensed and certified services including nursing and therapy services as well as PAS services. 0n 06/27/22 at 3:15 PM, the surveyor reviewed the QAPI black three ring binder labeled Alpha – MK Healthcare, Inc. Quality Assurance Performance Improvement Manual provided by the Office Manager. Review of the QAPI plan, QAPI committee meeting minutes, agency annual evaluation, and other documents in the QAPI binder provided revealed no evidence of inclusion of the PAS clients and program in the QAPI program for 2019, 2020, and 2021. The QAPI review also found no evidence of a representative sample of services furnished to clients contained in both active and closed records; and no evidence of a determination that services have been performed as outlined in the individualized service plan or plan of care. Review of the QAPI documents provided revealed no evidence of performance improvement projects for 2019, 2020 and 2021. Review of the QAPI committee meeting minutes dated January 7, 2022, April 4, 2022, October 15, 2021, July 9, 2021, April 9, 2021, January 12, 2021, July 3, 2020, and October 4, 2020, and April 3, 2020 revealed no therapy representative on the QAPI committee. The QAPI committee meeting minutes dated January 7, 2022, April 4, 2022, October 15, 2021, July 9, 2021, April 9, 2021, and July 3, 2020 revealed signatures by RN A who was listed as the Director of Nurses. The meeting minutes documented January 12, 2021 listed RN B as the Director of Nurses, and RN A as a “RN.” The surveyor observed the meeting minutes had signatures beside Director of Nurses and RN that looked similar. The surveyor observed the meeting minutes from April 3, 2019 and January 4, 2019 had signatures that looked different. Review of the agency Quality Assessment Performance Improvement program read in part: “Alpha MK Healthcare Inc will enhance organization performance by fulfilling the mission. The program will be ongoing and focused on client outcomes that are measurable. Our delivery systems will be reviews and analyzed in order to provide quality care and outcomes…Development of important measure/indicators must focus on the following: client / patient care, thru audit of both active and discharged patient charts, agency processes, and perceived or potential problem areas, and Adverse Events / OASIS generated reports … The Owner / Licensee: responsible for the overall administration and direction of the Agency, to include: Adopt, implement, enforce, and monitor adherence to QAPI policies, Ensure compliance with regulations, Ensure that safe, professional, quality health care is provided to clients … Administrator: These leaders are responsible for the following: A fundamental knowledge of the background, principles and techniques of performance improvement. Allocation of adequate resources for assisting and improving organization performance. Assignment of staff to participate in performance improvement activities…. Director of Nurses: The director must have a fundamental knowledge of performance improvement. The director is responsible for the following: Organization performance of the agency. Implementing plans based on the results of performance measure. Delegating an individual to coordinate performance activities. Involvement of all staff and not just one individual….” An interview was conducted with the Alternate Administrator on 06/30/2022 at 4:12 PM. The surveyor reviewed the QAPI record findings and asked how the PAS program was included in the QAPI program. The Alternate Administrator stated that the PAS program had never been included in the QAPI program. The surveyor asked how the agency measured significant outcomes for optimal care for the personal assistance program. The Alternate Administrator stated he did not know the PAS clients needed to be included in the QAPI plan. The surveyor asked about an analysis of a representative sample of services furnished to clients contained in both active and closed records in the QAPI program documents. The Alternate Administrator stated the consultant did that. The surveyor stated the last documentation in the QAPI documents provided by a consultant was from 2015. The surveyor asked if there was any other documentation of QA activities, including record reviews of active and discharged records for PAS and L & C clients. The Alternate Administrator pointed to the QAPI manual reviewed and stated “that is what we have.” The surveyor asked about how the agency made a determination that services had been performed as outlined in the individualized service plan or plan of care. The Alternate Administrator stated: “We don’t do it.” The surveyor asked about the Performance Improvement Projects. The Alternate Administrator stated RN A did the QA for the agency. The surveyor asked why there were no performance improvement projects in the QAPI committee meeting minutes for 2019, 2020, and 2021. The Alternate Administrator stated it was because “the previous surveyor did not tell us about that.” The surveyor asked if the agency had discussed, planned, and conducted any performance improvement projects for the last three years. The Alternate Administrator stated they didn’t have any current patients, so they were not doing any. The surveyor asked about the outcome of the agency having no projects planned or conducted for the three years. The Alternate Administrator stated the agency had a hard time since Medicare stopped paying the agency and they had been focusing on paying the taxes owed and the cost report, and the Alternate Administrator stated his health had not been good the previous year and had been in and out of the hospital and was better now, but some things had not been done. The surveyor asked about the effect on the patients of the agency not conducting the required performance improvement activities. The Administrator stated that they didn’t have any active patients (for the Licensed and Certified category) since March or April 2021. The Administrator stated the agency would be accepting patients in the future and were receiving referrals but had not accepted any new clients for about a year while they worked to resolve the other issues. An interview was conducted with RN A on 07/01/2022 at 2:24 PM. The RN stated she was not currently and had never been the DON for the agency. An interview was conducted with RN B on 07/07/2021 at 7:54 AM. The surveyor asked about the Supervising Nurse for the agency. The RN stated they had not been the Supervising Nurse for the agency since 2019, and “the agency just put your name on the paperwork because they don’t want to pay for a DON.” The RN stated she was “just an RN for the agency” and completed OASIS assessments and a few visits for the agency until the end of 2019. The RN stated they had retired when COVID started. An interview was conducted with the Alternate Supervising Nurse on 07/08/2022 at 8:28 AM. The Alternate Supervising Nurse stated she had been the Alternate DON for a long time and couldn’t remember when she started in that role. The surveyor asked who the current Supervising Nurse was for the agency. The Alternate Supervising Nurse stated: “I think it is [RN B] until 2021, and then it was [RN A].” The surveyor asked how long it had been since the Alternate Supervising Nurse had taken over for the Supervising Nurse. The Alternate Supervising Nurse stated she had never been the Supervising Nurse. The surveyor asked when the last time the Alternate Supervising Nurse worked for the agency. The Alternate Supervising nurse said: “Not since COVID, so 2019 or early 2020.” An interview was conducted with the Alternate Administrator on 07/07/2022 at 2:00 PM. The surveyor showed the QAPI committee meeting minutes and asked why no therapy representative was included in the QI committee. The Alternate Administrator stated he didn’t know they needed a therapist and they only used contract therapy. The surveyor asked about the DON signature on the QAPI meeting minutes for January 7, 2022, April 4, 2022, October 15, 2021, July 9, 2021, April 9, 2021, and July 3, 2020 by RN A as the Director of Nurses, and the meeting minutes documented January 12, 2021 that listed RN B as the Director of Nurses, and RN A as a “RN.” The surveyor asked about the different looking signatures from the April 3, 2019 and January 4, 2019 meeting minutes. The surveyor asked if the DON was present during the meetings. The Alt Admin stated: “No, [RN A] was not present.” He stated “they (the meetings) were by telephone and RN A was never available by phone.” The surveyor asked why RN A’s signature was on the meeting minute forms. The Alt Admin stated: “I wrote RN A’s name in on those minutes.” The surveyor asked why the Alt Admin wrote the nurse’s name in when RN A did not participate. The Alt Admin stated: “I wrote in the names of all those who were supposed to be present.” The surveyor asked about the outcome for the agency clients and staff of not having a Supervising Nurse and therapist to participate in the QAPI committee meetings. The Alternate Administrator stated: “The last two years of the business, I have not paid attention. In Jan 2020 we had a problem with the state and because of the cost report in 2019, and whoever was in the state, they were paying us $5, and we are paying the staff, and we owe money for the cost report. They said we paid the PAS workers wrong and whoever is looking at the cost report made the mistake and they had to recoup the money back.”