Every finding on record at Altruist Home Heatlh Care Inc

• Purpose of visit: A recertification survey and complaint investigation • Entrance date: 11/15/2023 • Census: L&C-6 LHHS-33 PAS-38 • Complaint TX number: 95500 & 97659 • Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) The facility is in compliance with no violations cited.

• Purpose of visit: A recertification survey and complaint investigation • Entrance date: 11/15/2023 • Census: L&C-6 LHHS-33 PAS-38 • Complaint TX number: 95500 & 97659 • Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Utilization Review (UR) Quality Assessment Performance Improvement Plan (QAPI) Texas Uniform Licensure Portal (TULIP) Health and Human Services Commission (HHSC) HHS (Health and Human Services) Director of Nurses (DON) Plan of Care (POC) Milligrams (mg) Milliliter (ml) Plus (+) Every night at bedtime (qhs) As needed (prn) Capsule (cap) By mouth (po) Twice a day (bid) Tablet (tab) Skilled Nurse (SN) Week (wk) Health and Human Services Commission (HHSC) HHS (Health and Human Services) NSF (non-sufficient funds)

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: The agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. The Administrator failed to implement and maintain the agency's QAPI (Quality Assessment and Performance Improvement) Program for two (2021 and 2022) the two years reviewed. This failure could prevent the agency from monitoring the effectiveness and safety of agency services provided to the agency's patients. The failure could also prevent the agency from identifying problems, implementing corrective actions to ensure the health and safety of the agency's patients, and if necessary, revise policies. FINDINGS INCLUDED: QAPI binder review: 1. The binder did not contain an annual evaluation of the QAPI program for 2021 and 2022. During an interview on 11/28/2023 at 11:30 AM, with the Administrator, the surveyor discussed the above findings. The Administrator said, "I didn’t do the annual evaluations. There’s no reason it wasn’t done.” Agency policy titled "QAPI.1 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN” dated 030415, read in part: "...PURPOSE To develop a Quality Assessment Performance Improvement Plan (QAPI) ...implemented by the QAPI/Utilization Review (UR) committee, which captures significant outcomes essential to safe and quality care… POLICY Agency leaders will develop a plan that sets priorities for data collection and is reviewed and updated or revised at least once within the calendar year...by the QAPI/UR Committee...Performance improvement priorities identified …the measures must include the following as appropriate for the scope of services provided by the Agency: 1. Analysis of a representative sample of services furnished to patients contained in both active and discharged charts; 2. Negative patient outcomes; 3. Complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff,4. Infection control activities; 5. Medication administration and errors;…7. A determination that services have been performed as outlined in the individualized service plan, care plan or plan of care; 8. An analysis of patient complaints and satisfaction survey data; and 9. An annual evaluation of the total operation, including services provided under contract or arrangement ...PROCEDURE...F. QAPI documents will be kept confidential and be made available to DADS, [Department of Aging and Disability Services) staff or accrediting body surveyor upon request."

An Onsite Complaint Investigation entrance conference was conducted on 05/19/2022, with the Adm at 1:37 p.m. Intakes: # 335626; 341442 and 341457 Parent: Licensed and Certified Census: 25 Branch: Licensed and Certified Census: 8 An exit conference was conducted on 05/24/2022 with the Adm at 1:45 p.m. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency provided additional records at the exit conference. Verbal instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations Adm- Administrator Alt Adm- Alternate Administrator DON- Director of Nursing ADON- Alternate Director of Nursing PAS Sup- Personal Assistance Services Supervisor PAS- Personal Assistance Services Health and Human Services Commission (HHSC) TULIP- Texas Unified Licensure Information Portal A/N/E- Abuse, Neglect and Exploitation POC- Plan of Care SARS-Severe Acute Respiratory Syndrome SN-Skilled Nursing Physical Therapist (PT) Occupational Therapist (OT)

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to investigate complaints of care that failed to be furnished, in of one (Patient # 2) of one L&C patient whose record was reviewed with a complaint allegation that the agency failed to furnish OT and nursing services. The failure could cause the patient to be at risk of further instances of neglect, (care that failed to be furnished) and/or abuse and/or exploitation. The failure also caused a delay in the abuse, neglect, and exploitation investigation process. The failure had the potential to have a negative impact on the patients (health and Safety). FINDINGS INCLUDED: During the entrance conference on 05/19/2022 at 1:37 p.m. the surveyor requested the agency’s complaint log. Review of the “Incident and Accident” binder did not include any logged complaints since 05/29/2021. During an interview on 05/19/2022 at 2:45 p.m. the surveyor asked the Adm if the agency had any other complaint/investigation logs or binders. The Adm stated that there was not another binder and that the complaints were usually in that binder. She also stated that the agency had no complaints for 2022. The surveyor asked who handled the agency’s self-reported incidents. The Adm replied “That was [former Alt Adm/DON # 1] who reported those. They were not in that book?” The surveyor asked where the agency documented its complaints/investigations. The Adm stated that the complaints/investigations were documents in the patient records in the “notes.” Patient # 2’s record contained a Plan of Care with a start of care date of 02/07/2022 and a certification period of 07/07/2022 to 04/07/2022. The POC also revealed a principal diagnosis of Pneumonia due to SARS. The POC contained orders for SN visits two times per week for nine weeks, PT and OT to evaluate and treat. Review of Patient # 2’s record (patient from random sample) revealed a “general note” dated 03/22/2022 that the agency received a complaint on behalf of the patient and requested that Patient # 2 be discharged from the agency’s service due to complaint regarding occupational services provided by the agency’s contracted therapy services. The record also contained other general notes that revealed two more complaints, on 03/38/2022 and 03/29/2022, with concerns about Patient # 2’s services, in that “nursing had not been out in 2 weeks to see [Patient # 2.]” A review of TULIP on 05/24/2022 revealed that the agency had not self-reported the complaint of neglect for Patient # 2 to HHSC. There was no record in the complaint binder or in the patient’s record that showed the agency had completed an investigation and documentation of all components of the investigation within 30 days after receipt of the complaints, for Patient # 2, of A/N/E (in accordance with agency policy). An interview was conducted on 05/24/2022 at 1:29 p.m., and follow-up clarification telephone interview on 05/26/2022 at 9:57 a.m. with the Adm. The surveyor discussed why the agency had not completed its investigation and documentation within 30 days after receipt of the complaints, for Patient # 2, of A/N/E, in accordance with agency policy. The Adm replied, “It would have been documented if we had resolved the issue. It should have been documented.” The surveyor asked if former Alt Adm/DON # 1 was available. The Adm replied, “She hasn’t been here in a few weeks.” The surveyor also discussed how not completing its investigation and documentation within the 30-day timeframe could adversely affect the agency’s patients. The Adm stated that not reporting had the potential to “have a negative impact on the patients. Everything has to be documented. You have to be accountable.” Review of agency policy titled “RI.6 Resolution of Patient Conflicts, Grievances or Complaints” dated 083116 read in part: “…Procedure...E. Agency will complete the investigation and document all components of the investigation within 30 days after the receipt of the complaint…" Review of agency policy titled, “RI.1 Patient Bill of Rights and Responsibilities/Right of the Elderly” dated 083116 read in part: “…Rights of the Elderly…(f) An elderly individual may complain about the individual’s care or treatment. The complaint may be…communicated by a person designated by the elderly individual. The person providing the service shall promptly respond to resolve the complaint…”

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a designated alternate administrator who met the qualifications required for the position in an agency licensed to provide licensed and certified home health services, in one of one current Alternate Administrator whose personnel records was reviewed. Alt Adm # 2 did not meet the federal requirements to hold an undergraduate degree; and have experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. The failure caused the agency to have an alternate administrator who did not meet state and federal regulatory requirements. The failure could cause client care services to not be delivered efficiently and effectively. FINDINGS INCLUDED: During the entrance conference on 05/19/2022 at 1:37 p.m. the Adm identified Alt Adm # 2 as the current alternate administrator. On 05/23/2022 at approximately 4:12 p.m., the surveyor requested and the Adm provided the designation date to the position of alternate administrator, for Alt Adm # 2, as 03/31/2022. Review of Personnel Record: Alt Adm # 2 revealed that the record did not contain a job description for the position of alternate administrator. The record did include signed job descriptions for a receptionist/clerical position dated 12/16/2015 and an administrative assistant clerical position, dated 03/10/2016. The record also included an application dated 12/11/2015. The application did not show that Alt Adm # 2 met the federal regulatory requirement to have an undergraduate degree; and have experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. The application showed that Alt Adm # 2 had a high school diploma and had experience as a receptionist and “supervised staff” in hospitality service. The record did not include any reference checks. The personnel record did not include any records that indicated Alt Adm # 2 met the federal regulatory requirements for the position of alternate administrator. During an interview with Alt Adm # 2 on 05/24/2022 at 1:06 p.m., the surveyor asked Alt Adm # 2 to discuss the qualifications of an Alternate Administrator. The Alt Adm # 2 replied, “Complete the modules (pre-survey computer-based modules) and have an administrator certificate.” The surveyor discussed the above findings of why Alt Adm # 2 had not met the federal requirements prior to being designated to the position of alternate administrator. Alt Adm # 2 replied, “I thought assisting the Adm was meeting the qualifications.” Alt Adm # 2 also replied, “I don’t really know why we didn’t do a job description after we had the talk.” During an interview with the Adm on 05/24/2022 at approximately 1:15 p.m. and follow-up clarification telephone interview on 05/26/2022 at 9:57 a.m., the surveyor discussed the above findings and what adverse effects the agency’s clients could experience because the agency failed to have a designated alternate administrator who met the federal qualifications required for the position in an agency licensed and certified to provide home health services. The Adm replied, “Ultimately, it could affect whether or not services will be delivered efficiently and effectively.” Review of agency policy titled "LD.5 Responsibilities of The Administrator" revised 021414 read in part: "...Policy…A. An Administrator will be responsible but not limited to… 1. Agency defines the responsibilities of the…Administrator to include, but not limited to: ...6. Employ…qualified personnel…11. Ensure Agency will operate…in compliance with all applicable federal, state, and local laws and regulatory agencies… D. The license holder…will designate…an individual that meets qualifications and conditions to perform the responsibilities of the Administrator’s position in his/her absence…”