Every finding on record at Beyondfaith Homecare & Rehab of Abilene LLC

An entrance conference was conducted for a Relicensure and Recertification survey with the Administrator on 8/19/2024 at 2:30 p.m. Census San Antonio: 250 Licensed and Certified Home Health: 125 Licensed Home Health: 89 Personal Assistant Services:36 Hospice:0 Exit conference was conducted on 8/22/2024 at 5:00 p.m. with the Administrator. The preliminary findings were reviewed and discussed, and the agency was afforded the opportunity to provide additional information. Written instructions for submitting an acceptable plan of correction within 10 calendar days of receipt of the Statement of Licensure Violations were provided. NO DEFICIENCIES WERE CITED

An entrance conference was conducted for a Relicensure and Recertification survey with the Administrator on 8/19/2024 at 2:30 p.m. Census San Antonio: 250 Licensed and Certified Home Health: 125 Licensed Home Health: 89 Personal Assistant Services:36 Hospice:0 Exit conference was conducted on 8/22/2024 at 5:00 p.m. with the Administrator. The preliminary findings were reviewed and discussed, and the agency was afforded the opportunity to provide additional information. Written instructions for submitting an acceptable plan of correction within 10 calendar days of receipt of the Statement of Licensure Violations were provided. Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency PT- Physical Therapist PTA Physical Therapy Assistant

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 97 of 2391 assessments processed for the time period reviewed of 07/1/2023 to 8/22/2024. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time period of 07/1/2023 to 8/22/2024 was reviewed pre-survey. Review of the HHA Error Summary Report for the time-period of 07/1/2023 to 8/22/2024 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is 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 97 assessments and the percentage of assessments with this error was 4.06% of assessments completed by the Agency. During an interview with the Administrator on 8/22/2024 at 3:00 p.m., the Administrator acknowledged the above findings and will work on correcting the issue. The Administrator stated he understands the importance of timely, completed OASIS submisssions. Record review of an Agency policy titled,” Section 8: OASIS,” no date, revealed, “Administrative Staff Responsibility…Develop tracking mechanism to ensure documentation is submitted in required time frames. OASIS assessments should be reviewed to ensure that the data is complete and timely…”

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review and interview the agency failed to enforce a written policy for maintaining a current medication administration record for 1 of 1 active client (Client #2) whose record was reviewed. This failure places the agency's active clients at risk for adverse drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The Findings Included: Review of the Agency's Policy and Procedure Manual revealed a policy titled "Medical Record Content", dated 12/27/2023, revealed in part, "The Agency will initiate and maintain and individual and accurate medical record for each patent /client receiving care in compliance with all federal and state las and regulation…8. An updated medication profile to include medication, allergies and/or sensitives 9. Actual or potential drug/food interactions…10. The dose, time, date, and any adverse drug reactions of every dose of medication 11. Identification of individual administering the medication." During a home visit on 8/21/2024 at 12:00 p.m. with Client #2, RN B performed a discharge visit. Client #2 and the caregiver were present during the discharge visit. The discharge visit further revealed that RN B did not review Client #2’s current medication in the home in comparison to the physician orders prior to exiting the home. Further observation revealed RN B did not review medications with the family member or Client #2. During an interview with RN B at 12:30 p.m., RN B was asked why the medication were not reviewed with the patient and family on a discharge visit, RN B stated that he knew the physician of Client #2 very well. During a review of Client #2’s clinical record on 8/20/2024 at 4:00 p.m., revealed an admitting diagnosis of Parkinson’s disease and orthostatic hypotension (low blood pressure and dizziness when standing or sitting quickly). Home care services revealed that Client #2 received skilled nursing twice weekly for a change in condition and assess for falls. Clinical record also revealed that Client #2 received physical therapy once weekly. During an interview with the Administrator on 4/21/2024 at 1:15 p. m., the Administrator revealed that he believes that RN B as nervous being observed during the visit. The Administrator also stated that the medication review policy is usually followed. The Administrator also stated that the medication review in home visits is an essential part of a safe discharge.