Every finding on record at Bellcoa Home Health Service Inc

A recertification survey was conducted on 4/28/2025. The census was: L&CHHS: 88 LHHS: 0 PAS: 0 Abbreviations/Acronyms: HHA: Home Health Agency L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services PAS: Personal Assistance Services The agency is in substantial compliance with no deficiencies cited.

A recertification survey was conducted on 4/28/2025. The census was: L&CHHS: 88 LHHS: 0 PAS: 0 Abbreviations/Acronyms: HHA: Home Health Agency L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services PAS: Personal Assistance Services CDC: Centers for Disease Control and Prevention RN: Registered Nurse MSW: Medical Social Work PT: Physical Therapist OT: Occupational Therapist ST: Speech Therapist CFO: Chief Financial Officer SN: Skilled Nursing QAPI: Quality Assessment and Performance Improvement QA: Quality Assessment

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 record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 20 of 782 assessments processed for the time-period reviewed of 04/25/2024 to 04/25/2024. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: In a review of the HHA Error Summary Report for the period of 04/25/2024 to 4/25/2025, the report identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 20 out of 782 assessments and the percentage of assessments with this error was 2.56% of assessments completed by the Agency. In an interview was completed with the Administrator on 4/30/25 at 2:30 PM, the surveyor showed Administrator the “Home Health Error Summary” report which indicated that 20 OASIS assessments were late by the agency. The Surveyor asked the Administrator who was responsible for submitting assessments to OASIS. Administrator reported that was her responsibility and that they were never late without a reason. She cited the reason they got flagged as late was because some had to be pulled back and edited at some point. The Administrator asked what the agency's process was to ensure timely submissions of assessments. The administrator stated that she tracked this extremely closely, and was always aware what step of the process assessment submissions were in. She stated they go over the date every morning in their morning meeting. The Surveyor asked how late assessment submissions impacted patient care. The Administrator reported that it slows the process and prevents them from getting signed orders back from physicians, so it could put patients at risk for receiving care without orders. Review of the agency policy titled, “Criteria for Patient Admission and Discharge,” last reviewed 07/05/24, revealed a document that read in part, “An Initial Assessment for each skilled admission to the Agency will be completed by the appropriate health care professional within 48 hours of the referral, or as ordered by the physician, or per authorization by payor source prior to or at the time of admission.” The agency was unable to provide a policy specifying timelines to submit assessments to OASIS.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to follow acceptable standards of practice to prevent the transmission of infections in 3 out of 3 patients (Client 1, Client 2, and Client 5) observed during home visits. Failure of the agency to ensure compliance with infection control policy and hand hygiene procedures puts the patients and employees at risk for acquiring a preventable infection. Findings included: During an observation in Client 1’s home on 4/28/25 at 1:45 PM, the administrato r/supervising nurse was observed placing her bag directly on the patient’s floor. The administrator/supervising nurse washed her hands upon entering the home but did not sanitize hands again throughout the visit. Surveyor observed administrator/supervising nurse removing a blood pressure cuff (device to measure blood pressure), thermometer (device to measure temperature), pulse oximeter (Device to measure oxygen level), and stethoscope (device to listen to heart and lung sounds) from her bag and placed them directly on the patient’s table. There was no clean barrier placed on the table before to prevent contamination). The Administrator/supervising nurse proceeded to take vital signs using the equipment described and assess the patient without gloves. The equipment was placed back on the table after use. The Administrator/supervising nurse then used a disposable lancet from the patient’s equipment (small, single use sharp device that pricks finger to obtain small blood sample ) to poke the patient’s finger and take a sample of blood using a testing strip and glucometer (device that reads testing strips to measure blood sugar level). The administrator/supervising nurse did not wear gloves for the duration of this task and did not sanitize hands before or after. The administrator/supervising nurse then put on gloves to give the patient an injection. Hand hygiene was not performed after she removed her gloves. The administrator did not clean her equipment (blood pressure cuff, pulse oximeter, thermometer, and stethoscope) before returning them to her bag. During an observation in Client 2’s home on 4/28/25 at 2:55 PM, the administrator/supervising nurse placed one of her bag’s directly on the patient’s floor and one of her bags on the patient’s chair. The administrator washed her hands upon entering the home but did not sanitize hands again throughout the visit. The administrator/supervising nurse did not clean equipment (pulse oximeter, blood pressure cuff, thermometer, and stethoscope) before returning to bag. The administrator used gloves to assess the patient’s legs, removed them, did not sanitize hands, and then donned new gloves to perform wound care. After performing wound care, the Administrator removed her gloves, did not sanitize hands, then donned new gloves to tape the clean bandages to the patient’s leg. During an observation in Client 5’s home on 4/29/25 at 12:38 PM, RN A entered the Client 5’s home and placed her bag directly on the patient’s chair. RN A did not wash hands or use hand sanitizer before entering her bag to remove equipment. RN A placed equipment (stethoscope, thermometer, pulse oximeter, and blood pressure cuff) directly on Client 5’s open Admission Binder (binder provided by the agency that stays in the patient’s home where nurses document vital signs). RN A put on a pair of gloves to assess the patient. RN removed these gloves, did not perform hand hygiene, then put on new gloves. She then wiped down her equipment with a disinfectant wipe before returning the equipment to her bag. RN removed gloves and did not perform hand hygiene before leaving the patient’s home. During an interview with RN A on 4/30/25 at 8:34 AM, the surveyor asked if she was aware of the agency’s policy on bag technique for infection prevention. RN A stated she knew the policy but could not recall the details. The surveyor explained the agency policy on bag technique to use a barrier between the bag and the surface it is place on, and RN A stated she usually used a barrier but did not today. The surveyor asked if RN A ever sanitized or washed her hands when performing care to a patient. RN A stated that she does sanitize her hands when she gets to her car. RN A also stated that she usually had a disinfectant wipe for cleaning hands that she used in patients’ homes, but she did not use it today. The surveyor asked how not sanitizing hands and using improper bag technique could affect patient care. RN A stated that it could affect patient care because it was an infection risk to the patients. During an interview with the Administrator on 4/30/25 at 2:15 PM, the Surveyor asked the Administrator/supervising nurse if she was aware of the agency’s policy on bag technique. She stated that she was. She stated she should not have put her bag on the floor. She stated the agency’s policy was to use a barrier when placing bags down in patient homes. Surveyor also shared observations of the lack of hand hygiene practices to prevent transmissions of infections in all home visits. The Administrator/Supervising nurse stated that she should have worn gloves when checking the Client 1’s blood sugar and should have cleaned hands before and after. She stated she did this because Client 1 is a long-term client of hers and she feels she loses the objectivity of a clinician when she cares for patients for a long time. The administrator/supervising nurse stated she was aware of the agency policy on exposure control, infection prevention, and hand hygiene. The surveyor asked who was responsible for enforcing the agency’s infection control policies and ensuring staff are trained in preventing infections. The Administrator/ supervising nurse responded that it was her responsibility to educate staff on infection prevention, and that she does this every month during their morning meetings with all staff. She stated all clinical staff have been trained in infection prevention. The surveyor asked how poor infection prevention could affect patient care. Administrator stated that it could cause infections to spread among patients, particularly wound infections which could have severe consequences. Record review of the agency’s policy revealed a document titled “Bag Technique,” last reviewed 11/01/2020, that read in part, “In the patient/client home, a barrier (such as newspaper, paper towel, small trash bag, etc.) is to be placed under the bag. Bags should never be placed on the floor. Prior to the provision of care antimicrobial soap and paper towels or alcohol-based hand-rub is removed and hands are cleansed…After cleansing hands, the supplies and/or equipment needed for the visit are removed from the bag. When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe, and/or soap and water as appropriate and placed on a clean surface, hands are cleaned per CDC guidelines (see Hand Hygiene policy), and clean equipment and supplies are returned to the bag.” Record review of the agency’s policy revealed a document titled “Hand Hygiene,” last reviewed 04/14/23, that read in part, “Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: 1. Prior to initial entry into the supply bag. 2. Immediately before touching a patient. 3. Before performing an aseptic task […] or handling invasive medical devices […] 7. After contact with blood, body fluids, or contaminated surfaces. 8. After removing gloves.” Further review revealed the document also read, in part, “All Agency staff providing patient care will perform hand hygiene in accordance with Center for Disease Control and Prevention (CDC) recommendations. Record review of the agency’s policy revealed a document titled “Infection Control Program,” last reviewed 01/01/25, that read in part, “The Agency will follow the accepted standards or practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.” Review of resource information sourced from the CDC (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, 5/1/25) revealed that hand hygiene should be performed during the following times: “Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.” Further review of this source revealed the following recommendations on when to wear gloves: “When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment).” It also reads, in part, “If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings.”

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include all skilled professionals in their QAPI meetings in 6 out of 6 QAPI meetings (7/15/2022, 1/11/2023, 07/07/23, 12/22/23, 7/5/24, 12/20/24) in the 3 years reviewed (20222, 2023, and 2024). In 2 out of 6 meetings reviewed, (7/15/22 and 1/11/23), no PT attended the QAPI meetings. In 6 out of 6 QAPI meetings (7/15/2022, 1/11/2023, 07/07/23, 12/22/23, 7/5/24, 12/20/24), no OT, ST, or MSW were in attendance. Failure of the agency to have all skilled professionals represented in the QAPI program resulted in missed opportunity for the therapists and MSW to provide clinical input on best practices and contribute to improving patient care. Findings included: Review of document titled “[Agency] QUAPI [sic] Meeting Attendance,” dated 7/15/2022, revealed that attendees included the Administrator/Supervising Nurse, Alternate Administrator/Alternate Supervising Nurse, CFO, Medical Director, and External Consultant A. Review of document titled “[Agency] QUAPI [sic] Meeting Attendance,” dated 1/11/2023, revealed that attendees included the Administrator/Supervising Nurse, Alternate Administrator/Alternate Supervising Nurse, CFO, Medical Director and External Advisor A. Review of document titled “QUAPI [sic] MEETING,” dated 07/07/23, revealed that attendees included Administrator/Supervising Nurse, CFO, PT A, External Advisor A, Medical Director, PT B, Community liaison, Front Office Staff A, and External Advisor B Review of document titled “QUAPI [sic] MEETING,” dated 12/22/23, revealed that attendees included the Administrator/Supervising Nurse, CFO, PT A, External Advisor A, Medical Director, PT B, Community liaison, Front Office Staff A, and External Advisor B. Review of document titled “QUAPI MEETING,” dated 7/5/24, revealed that attendees included the Administrator, CFO, PT A, External Advisor A, Medical Director, PT B, Community liaison, and Front Office Staff A. Review of document titled “QUAPI MEETING,” dated 12/20/24, revealed that attendees included the Administrator, CFO, PT A, External Advisor A, Medical Director, PT B, Community liaison, and Front Office Staff A. In an interview with the administrator on 4/28/24 at 10:49 AM during the entrance conference, the administrator confirmed the scope of services provided includes SN, PT, OT, ST, and MSW. In an interview with the administrator on 4/29/24 at 2:33 PM, the surveyor asked the Administrator if anyone from the specialties of OT, ST, or MSW attended QAPI meetings. The Administrator stated they do not. Surveyor asked why no one representing all skilled professionals attended the meetings. The Administrator stated, “there really isn’t a reason”. In an interview with the administrator on 4/28/24 at 10:49 AM, during the entrance conference, the Administrator confirmed that the agency offers Skilled Nursing, Occupational Therapy, Speech Therapy, Physical Therapy, and Medical Social Work. In an interview with the administrator on 4/28/24 at 12:28 PM, the surveyor asked if they have clients receiving medical social work services. The administrator stated that they do sometimes, and that the medical social worker works part-time for the agency and sees clients as needed. In an interview with the administrator on 4/30/24 at 2:22 PM, the surveyor asked if the Administrator was aware that the agency policy stated that QAPI meeting attendance should include someone representing the scope of services provided by the agency. The administrator stated she was not aware of this. The Surveyor asked who was responsible for planning QAPI meetings and inviting attendees. The Administrator stated that a third-party QA group was responsible for presenting at the QAPI meetings, but that she usually helped coordinate the meetings themselves. The Surveyor asked the administrator how not including all services in the QAPI meetings could affect patient care. The Administrator stated that “it is important for everyone to be there, so we can all learn.” In a record review of agency policy titled, “Quality Assessment and Performance Improvement Plan,” last reviewed 10/01/2016, revealed a document that read in part, “The QAPI Committee will consist of, at a minimum, the Administrator, Supervising nurse or therapist, and individuals representing the scope of services provided by the Agency. The QAPI Committee will meet at least twice a year or more often, if needed.”

An Entrance Conference was conducted on 04/20/2022 with the Administrator at 9:00 a.m. The agency representative was informed that the purpose of the visit was a Recertification survey, The agency census was: Austin: L&CHHS- 39, LHHS- 0 An Exit Conference was conducted on 04/22/2022 with the Administrator and CFO at 10:45 a.m. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations L&CHHS- Licensed & Certified Home Health Services LHHS- Licensed Home Health Services CFO- Chief Financial Officer QAPI- Quality Assessment & Performance Improvement D/C- discharge

An Entrance Conference was conducted on 04/20/2022 with the Administrator at 9:00 a.m. The agency representative was informed that the purpose of the visit was a Recertification survey, The agency census was: Austin: L&CHHS- 39, LHHS- 0 An Exit Conference was conducted on 04/22/2022 with the Administrator and CFO at 10:45 a.m. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations L&CHHS- Licensed & Certified Home Health Services LHHS- Licensed Home Health Services CFO- Chief Financial Officer QAPI- Quality Assessment & Performance Improvement D/C- discharge

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to enforce its discharge planning process to provide a patient or patient’s responsible party with written notice of its intent to discharge the patient for 2 of 2 discharged patients (Patient #7 and #8) who were discharged for goals met. This may cause harm in that patients may not receive necessary care and services as ordered or have sufficient time to arrange transfer to a different agency. Findings Included: Review of the agency’s policy and procedure manual revealed a policy entitled “PATIENT DISCHARGE, PE.6”, which read in part “B. Patient Discharge- 4. Agency intending to discharge a patient will perform the following: Provide written notification to the patient’s parent, family, spouse, significant other or legal representative. 5. Agency will ensure delivery of the written notification no later than five (5) days before the date on which the patient will be discharged.” Review of the patient record for Patient #7 revealed a start of care date of 08/17/2021 with a diagnosis of Hypertensive Chronic Kidney Disease, Dementia and Atrial Fibrillation. Further review of the clinical record revealed the patient was discharged on 04/11/2022 for goals met. The record did not contain documentation that a written discharge notice was provided prior to discharge. Review of the patient record for Patient #8 revealed a start of care date of 10/11/2021 with a diagnosis of Pressure Ulcer of Sacral Region- Stage 3, Acute Kidney Failure, Malignant Neoplasm of Overlapping Sites of Rectum, Anus, Anal Canal and Rectosigmoid Junction. Further review of the clinical record revealed the patient was discharged on 02/03/2022 for goals met. The record did not contain documentation that a written discharge notice was provided prior to discharge. An Interview was conducted on 04/21/2022 with the Administrator at 10:35 a.m. The clinical records for Patients #7 and #8 were reviewed and documentation that these patients received a written discharge notice prior to discharge was requested for review. The Administrator acknowledged written discharge notice was not provided. Surveyor asked what factors may have caused this noncompliance to occur. Administrator stated this was due to a knowledge deficit on her part.

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: Based on record review and interview, the agency failed to enforce a policy to ensure that the QAPI committee met at least twice a year for two of two years reviewed (2020 and 2021). This failure caused the agency to be unable to identify problems and institute changes in all areas in the provision of patient care to the agency patients. Findings Included: According to the Texas Administrative Code §558.287(c) “Frequency of QAPI Committee meeting. The QAPI Committee must meet twice a year or more often if needed.” Review of the agency’s Policy and Procedure Manual revealed a policy entitled “QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN, QAPI.1”, which read in part “The QAPI committee will meet at least twice per year or more often, if needed.” Review of the agency’s QAPI program revealed no documentation that QAPI committee meetings were held in 2020 and one meeting was held in 2021. An Interview was conducted on 04/21/2022 with the Administrator at 11:10 a.m. Documentation of QAPI committee meetings for 2020 and 2021 were requested for review. The Administrator stated QAPI Committee meetings were not conducted in 2020 “due to COVID-19” and only one committee meeting was conducted in 2021. The agency’s policy regarding frequency of QAPI committee meetings was reviewed and the Administrator acknowledged the agency failed to comply with this policy.