Every finding on record at Best Shepherd Home Heatlh Services of Dallas, Inc.

• Purpose of visit: Recertification/Relicensure Survey • Entrance date: 04/09/2024 • Census: L&CHHS-1, LHHS-0, PAS-16 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 deficiencies cited.

• Purpose of visit: Recertification/Relicensure Survey • Entrance date: 04/09/2024 • Census: L&CHHS-1, LHHS-0, PAS-16 Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Quality Assessment Performance Improvement Plan (QAPI)

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce its written policy regarding the time frame for countersignature of physician orders in that the agency failed to ensure that the physician signed the orders within 60 days as specified in the agency's policy for one of one active (Patient #1) patients whose clinical record reviewed in that: 1. Patient #1's Plan of Care order dated 12/13/2023 to 02/10/2024 did not have a physician signature. 2. Patient #1's Plan of Care order dated 02/11/2024 to 04/10/2024 did not have a physician signature. This failure had the potential to result in the physician failing to review the written orders in a timely manner to ensure interventions ordered complied with the physician's treatment plan and had the potential to result in the agency providing inappropriate or ineffective interventions or failing to provide needed interventions. Review of Patient #1's clinical record revealed a SOC date 12/13/2023 and contained: A plan of care signed by the Director of Nurses/Administrator dated 12/13/2023 for certification period 12/13/2023-02/10/2024 which included the primary diagnosis of Type 2 diabetes with diabetic autonomic (poly) neuropathy (A long-term condition in which the body has trouble controlling blood sugar and using it for energy. Neuropathy is the medical term for nerve damage). Further review of the plan of care revealed no physician signature. A plan of care signed by the Director of Nurses/Administrator dated 02/10/2024 for certification period 02/10/2024-04/10/2024 which included the primary diagnosis of Essential (primary) hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). Further review of the plan of care revealed no physician signature. In an interview with the Administrator on 04/11/2024 at approximately 11:49 AM, the surveyor presented the above findings. The Administrator said, "We’ve been calling and haven’t been able to get the signatures.” The surveyor asked if the orders were faxed or taken to the physician’s office for signatures. The Administrator said, “We sent faxes but have not gone to the physician’s office.” The surveyor asked for the fax confirmations. The Administrator said, “We don’t keep copies of the fax confirmations.”

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 interview and record review, the agency failed conduct performance improvement projects for 2 of 3 (2022 and 2023) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the agency's program for which performance could be improved. The findings included: In an interview with the Administrator on 04/10/2024 at approximately 10:00 AM, the surveyor requested the QAPI documents and asked who was responsible for the QAPI program. The Administrator said, “I’m responsible for the QAPI program.” Review of the documentation regarding the agency's QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT PLAN Program included no documentation to indicate the agency had conducted performance improvement projects, the reasons for conducting the projects or the measurable progress achieved on the projects for the years of 2022 and 2023. During an interview on 4/10/2024 at 11:29 AM, with the Administrator, the surveyor discussed the above findings. The Administrator said, "It was overlooked. The surveyor asked who was on the QAPI committee. The Administrator said,” It’s just me because we are not using any therapies or social workers.” Agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT Program QAPI.5" revised 011318 read in part: "...III. The QAPI Plan will be developed based on…E. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually…2. The Agency will document the quality improvements projects undertaken…”